UNITED STATES—Dear Toni, please explain why my Mom must pay 100 percent for her Skilled Nursing 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 offered the option of her being placed into rehab/skilled nursing facility to build her strength backup.

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 Skilled Nursing 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 .

Hi, Tom: You are right, Tom! 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 new Medicare rule called the Medicare Outpatient Observation Notice (MOON) began in March 2017 and has made it harder to qualify.

This rule is explained in the Medicare & You handbook titled, “Am I an inpatient or outpatient?” Learn how an overnight hospital stay does not always mean you are an inpatient and may have to pay more for your skilled nursing facility care.

The MOON rule is explained in the Medicare & You handbook and most that are enrolled in Medicare may have missed this information. 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.”

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.

Below is what you, your family members or caregivers need to know when having a hospital stay:

  1. Remember the MOON rule applies to those on “Original Medicare” and not Medicare Advantage plans. MAPD plans have their own Skilled Nursing facility qualifications.
  2. Discuss the hospital procedure with your physician/surgeon regarding whether this will be an inpatient or outpatient stay.
  3. Remember you only become an inpatient once the hospital, not your doctor, “formally admits” you with a doctor’s order.
  4. You or a family member should ask every day if you or your loved one is an inpatient or an outpatient.

Since your mother was not “formally admitted,” then she did not meet Skilled Nursing requirements and Medicare will not pay under Part A.

If you are still confused and would like to discuss your specific Medicare circumstances email info@tonisays.com and the Toni Says® team can help you.

Toni King, author of the Medicare Survival Guide® Advanced is giving a $5 discount on the Medicare Survival Guide® Advanced book and bundle packages as a Thank You for the Toni Says® newspaper article readers. Go to www.tonisays.com to purchase.