Medicare expert, Toni King explains under what circumstances Medicare does and doesn’t pay for skilled nursing care. The answer may surprise you!
Please explain why my mom must pay 100% for her skilled nursing facility stay. She recently slipped and fractured her back, requiring a back brace. She was released from the hospital after only a 2-day stay. We were offered the option of her being placed into a rehab/skilled nursing facility to build her strength back up
Now her Medicare supplement has denied paying anything for this stay because Medicare has said she did not meet Medicare’s qualification for a skilled nursing stay. Her current bill is over $12,000. No one explained what the skilled nursing rule was. What should we do? I thought Medicare paid for skilled nursing. Am I wrong?
Tom, from Bellaire, TX
Does Medicare Pay For Skilled Nursing?
You are right! Medicare does pay for skilled nursing when one meets Medicare’s skilled nursing requirements. Unfortunately, your mother did not meet Medicare’s requirements and must pay the total amount.
A Medicare rule called the Medicare Outpatient Observation Notice (MOON) began in March 2017 and has made it harder to qualify.
This rule states that staying overnight in a hospital doesn’t always mean you’re an inpatient. You only become an inpatient when a hospital formally admits you as an inpatient and after a doctor orders it. You’re still considered outpatient if you haven’t been admitted, even if you’re getting ER services, under observation, having outpatient surgery or lab tests, or receiving x-rays.
Toni Says: Always ask if you’re considered inpatient or outpatient each day during your stray since it affects what you pay.
Tom, it seems that your family members may not have been given the MOON (Medicare Outpatient Observation Notice) during your mother‘s hospital stay. The MOON form is provided in written form that is signed and dated with an oral explanation from the facility no later than 36 hours from the time the Medicare patient begins receiving outpatient observation services. This time limit is considered the new two-midnight stay observation policy and extends the time limit to qualify for Medicare-paid skilled nursing.
What do You Need to Know During a Hospital Stay?
Below is what you, your family members, or caregivers need to know when having a hospital stay:
- Remember the MOON rule applies to those on “Original Medicare” and not Medicare Advantage plans. MAPD plans have their own skilled nursing facility qualifications.
- Discuss the hospital procedure with your physician/surgeon regarding whether this will be an inpatient or outpatient stay.
- Remember you only become an inpatient once the hospital, not your doctor, “formally admits” you with a doctor’s order.
- You or a family member should ask daily if you or your loved one is an inpatient or an outpatient.
Since your mother was not “formally admitted, ” she did not meet Skilled Nursing requirements, and Medicare will not pay under Part A.
Toni King is an author, columnist, and radio and TV personality who specializes in Medicare, Social Security, and long-term care planning. While conducting a Medicare workshop in 2009, Toni was approached by a member of the audience who had received incorrect information about his Medicare Part B enrollment from Social Security. After taking a couple of days to help the gentleman straighten out his overwhelming problem, Toni’s new mission had become clear. Following more than 27 years as a top sales leader in the Medicare insurance industry, Toni would become an advocate for Americans receiving Medicare. Since then, Toni has devoted her life and career to putting Medicare into “people terms” with the help of her books, consultations, workshops, and website, ToniSays.com. Read more from Toni King here!