Medicare Rule…No One Remembers!

 Dear Toni,

Just a quick note to say that my mother had to go into the hospital this week with COVID that caused a urinary tract infection and pneumonia.   She had slipped and bumped her head, but no concussion.   Very weak, so we are asking that she be placed into rehab/skilled nursing to build her strength backup.

Anything I should be aware of since I had her unenroll last Medicare Annual Enrollment from a Medicare HMO to her new Medicare Supplement? I know that the Medicare Supplement pays if Original Medicare pays.

I cannot remember specifics about a Medicare rule you wrote regarding skilled nursing. I know some of the Medicare rules have changed.  Please explain what her options can be?  She is on a limited income, and I would have to help her pay in case Medicare does not.  Thanks, Tom from Bellaire, TX

Hi, Tom:

The Medicare rule is explained in the Medicare & You handbook titled, “Am I an inpatient or outpatient?” One must learn that an overnight hospital stay does not always mean you are an inpatient and that you may have to pay out of your own pocket for a skilled nursing facility care.

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 with more detail in the Medicare & You handbook and most who 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, be sure that your mother or any family member who is having a hospital stay is provided the MOON (Medicare Outpatient Observation Notice) 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.

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, as Medicare Advantage Plans have their own rules and options regarding inpatient/outpatient services.
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.

Have a Medicare concern or question, please email the Toni Says® office at info@tonisays.com or call 832/519-8664.