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Janie Slaven: TONI SAYS: Need skilled nursing for my mother

Times-Tribune - 11/4/2023

Nov. 3—Dear Toni,

My mother had to go into the hospital this week with a urinary tract infection and pneumonia, then she slipped and bumped her head. No concussion, but she is very weak, so we are asking that she be placed into a skilled nursing facility to build her strength back up.

Since she disenrolled at the last Medicare Annual Enrollment from a Medicare Advantage HMO to her new Medicare Supplement, is there anything I should be aware of regarding skilled nursing?

You once wrote about a Medicare rule regarding skilled nursing, but I cannot remember the specifics. What options will she have? My mother is on a limited income, so I would have to help her pay for her stay in case Medicare does not. Thanks, Toni.

—Tom from Las Vegas

Hi Tom:

The Medicare Outpatient Observation Notice (MOON) applies to those with an Original Medicare Part A hospital stay. It does not apply to those with Medicare Advantage plans. Since your mother is now enrolled in a Medicare Supplement, she will have to follow the Medicare rule about skilled nursing.

The MOON rule is explained in detail on page 28 of the Medicare & You handbook under "Am I an inpatient or outpatient?" The handbook states, "Whether you're an inpatient or an outpatient affects how much you pay for hospital services and if you qualify for Part A Skilled Nursing Facility care." Tom, this rule will affect your mother's skilled nursing. Briefly:

— You only become an inpatient once the hospital, not your doctor, "formally admits" you with a doctor's order.

— You are an outpatient when receiving emergency or observation services, even if it results in an overnight stay in the hospital, if you have not had a "formal inpatient admission." Formal admission is extremely important in order to qualify for a skilled nursing stay where Medicare will cover the cost.

Each day you must stay in the hospital, you or your caregiver should always ask the hospital, your doctor, or a hospital social worker/patient advocate if you are an "inpatient or outpatient." When under observation as an outpatient for more than 24 hours, you must receive a Medicare Outpatient Observation Notice (MOON).

Tom, under Part A for a skilled nursing stay, Medicare will only cover semi-private rooms with meals, skilled nursing, and therapy services after a 3-day minimum medically necessary "inpatient" hospital stay. Below are two different scenarios, referenced on the Medicare website, that show whether one has met the inpatient hospital stay requirement to qualify for skilled nursing covered by Medicare:

— Situation 1: John came to the Emergency Room and spent one day getting observation services. Then, he was formally admitted to the hospital as an inpatient for 2 more days.

Is John's Skilled Nursing Facility (SNF) stay covered? No. Even though he spent 3 days in the hospital, John was considered an outpatient while getting the Emergency Room and observation services. These days don't count toward the 3-day inpatient hospital stay requirement. Medicare did not pay for John's SNF stay because he did not qualify.

— Situation 2: Sally came to the Emergency Room and was formally admitted to the hospital with a doctor's order as an inpatient for 3 days. Sally was discharged on the 4th day.

Is Sally's SNF stay covered? Yes. Sally met the 3-day inpatient hospital stay requirement for a covered SNF stay. Medicare did pay for Sally's SNF stay because she met the 3-day minimum medically necessary inpatient hospital stay with the 4th day discharged.

Readers, qualifying for a skilled nursing stay can be stressful because it must be done properly. Make sure you follow the rules to ensure your stay is covered!

Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email or call 832-519-8664.


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