UNITED STATES—Dear Toni, just a quick note to say that my mother had to go into the hospital this week as she has the flu, a urinary tract infection and pneumonia. She 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.

She changed from her company retirement Medicare Advantage PPO plan this summer to her new Medicare Supplement Plan G. 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 the inpatient/outpatient rules have changed.  Please explain what her options can be? Do not want my mother to pay more than she must.  Thanks, Tom from Tampa, FL.

Hi, Tom: The Medicare rule is explained in the Medicare & You handbook titled, “Am I an inpatient or outpatient?” Learn how a hospital stay does not always mean you are an inpatient and may have to pay more or all your 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. Medicare Advantage plans have different rules regarding rehab/skilled nursing stays.

The MOON rule is explained with more detail in the Medicare & You handbook and most who are enrolled in Original 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.”

America needs to be aware that a 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.

Tom…this means that you should have received the MOON (Medicare Outpatient Observation Notice) within 36 hours that your mother entered the hospital.

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 or your family member 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.”

Not enrolled in a Medicare Prescription Drug Part D plan and the hospital stay falls in “Under Observation” or MOON, you may also have to pay for the drugs administered because the outpatient stay is under Part B which does not cover prescriptions given orally.

Toni King, author of the Medicare Survival Guide® is giving a $5 discount on the Medicare Survival Guide® Advanced book to Toni Says® Medicare column readers. Email Medicare questions to info@tonisays.com or call 832-519-8664.

Written By Toni King