UNITED STATES—Toni: Last week you wrote about how the MOON (Medicare Outpatient Observation Notice) rule affects “Original Medicare”.  My husband has enrolled in a Medicare Advantage HMO and I am wondering how this rule will affect his hospital stay. Thank you, Maria from Cleveland, OH.

Maria: The MOON rule only affects those who are enrolled in “Original Medicare” with or without a Medicare Supplement. The rule does not affect those enrolled in a Medicare Advantage plan.

A Medicare Advantage HMO plan has its own process on inpatient and outpatient surgery or hospital stay with a referral only system. With a Medicare Advantage PPO plan, there is not a referral process, but the facility or provider must be willing to bill the Medicare Advantage plan.

The Medicare and You Handbook explains what is a Medicare Advantage plan or what a Medicare Supplement/Medigap “Original/ Traditional Medicare” is? The Medicare and You Handbook does not compare the differences between the plans as listed below:

  • Medicare Supplement:
  • A Medicare Supplement/Medigap Plan works directly with Original/Traditional Medicare. Medicare will pay its share of the Medicare-approved amount for “medically necessary” covered healthcare costs. Then, your Medicare Supplement/Medigap will pay its share.
  • You chose which doctor, hospital, home health agency, skilled nursing facility, etc. that accepts Medicare assignment. You and your healthcare provider are in control of your healthcare.
  • With a Medicare Supplement/Medigap, you have a monthly premium that may increase the premium rate each year.
  • You may enroll in and will pay separately for a “Stand alone” Medicare (Part D) Prescription drug plan. If you don’t enroll in a Part D prescription drug plan at the right time, be aware that there is a Part D penalty assessed when you do finally enroll and that penalty will last as long as you are enrolled in a Medicare Part D prescription drug plan.
  • Medicare Advantage Plan: 
  1. To qualify for the plan:
    1. You must be enrolled in both Medicare Parts A & B
    2. Live in the service area 6 months out of a year
  2. When you choose a Medicare Advantage Plan, then Medicare pays the insurance company a certain amount every month for your care if you are on the plan. Your Part B must always be in effect.
  3. When you go to the doctor or visit your pharmacist, you must only use your Medicare Advantage insurance card, not your Medicare (red, white, and blue) card.
  4. A Medicare Advantage Plan must provide all your Part A and Part B benefits and some Medicare Advantage Plans have Part D prescription drug plans included.
  5. With a Medicare Advantage plan, you may have different co-pays, co-insurances, or deductibles to pay and have maximum out of pocket expenses to meet.
  6. Some Healthcare facilities like MD Anderson accept few Medicare Advantage plans. Talk to your provider or facility and make sure they accept the Medicare Advantage plan you want to enroll in.

Is the maze of Medicare confusing you? Call the Toni Says® Medicare hotline at 832-519-8664 or visit the Toni Says® Medicare webinars because it is what you don’t know that will hurt you!

Toni King, author of the Medicare Survival Guide® is giving a $5 discount on the Medicare Survival Guide® Advanced book.