Recently, my husband Jim fell from a ladder, shattering his hip and breaking his right leg. After emergency surgery, Jim was checked into a skilled nursing facility for rehab on his repaired hip.
I cannot remember specifics about a Medicare skilled nursing rule you discussed in your “Confused about Medicare” Zoom webinar. Some of the Medicare hospital rules are puzzling.
A friend recently had a skilled nursing stay and was billed more than expected, because she did not have the right amount of time as an inpatient. Please tell me what I should know for Jim’s skilled nursing stay.
Terry from Bellaire, TX
The Medicare rule is explained in the section of the Medicare & You handbook titled “Am I an Inpatient or Outpatient?” One must learn that a hospital stay doesn’t always mean you’re inpatient. Nor does this mean that you qualify for Medicare Part A skilled nursing facility care, or that you may have to pay 100% out of your own pocket.
This Medicare Outpatient Observation Notice (MOON) went into effect a few years ago and applies to those with an original Medicare hospital stay. It does not apply to those with Medicare Advantage Plans.
The MOON rule is explained in more detail in Medicare & You. The handbook states: “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, after a doctor orders it. You’re still an outpatient if you haven’t been formally admitted as an inpatient, even if you’re getting emergency department services, observation services, outpatient surgery, lab tests, or X-rays.
You or a family member should always ask if you’re an inpatient or an outpatient each day during your stay, since it affects what you pay and can affect whether you’ll qualify for Part A coverage in a skilled nursing facility.”
Make sure that a family member on original Medicare, who’s in the hospital, is provided the MOON (Medicare Outpatient Observation Notice) in written form. It must be 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.
Do not forget that the first two-day of a hospital stay is considered outpatient with a MOON notice. Some may have to pay 100% of their skilled nursing or rehab stay, if they have not been formally admitted as an inpatient with at least 3-day hospital stay with 4-day discharges.
Related: Medicare Part D: Why This Might Be the MOST Important!
The MOON continued…
Chapter 2 of the Toni Says® Medicare Survival Guide Advanced edition explains Medicare’s MOON notice and skilled nursing 3-day rule in easy-to-understand terms. 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. Advantage Plans have their own rules regarding
- Discuss the hospital procedure with your physician or surgeon regarding whether this
will be an inpatient or outpatient stay.
- You or a family member should ask every day if you or your loved one is an
outpatient or an inpatient that has been “formally admitted.”
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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!
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