Mom Has to Pay 100% for Skilled Nursing Stay…Why?

Dear Toni,

Please explain why my Mom must pay 100% for her Skilled Nursing stay. She recently slipped and fractured her back requiring surgery and a back brace.  She was released from the hospital after only a 2-day stay.  She was offered the option of 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 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, only when one meets Medicare’s Skilled Nursing requirements. Unfortunately, your mother did not meet Medicare’s requirements because her hospital stay was not long enough, 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 due to in-patient hospital stays not having the correct number of days.

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 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.”

The MOON (Medicare Outpatient Observation Notice) during her hospital stay must not have been presented to your mother or family members.  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.

The MOON rule is considered the two-midnight stay observation policy and extends the time limit to qualify for Medicare-paid Skilled Nursing. To qualify for an approved Medicare skilled nursing stay one must still have a 3-day formally admitted in-patient stay with the 4^th day discharged.

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.

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