Who pays for a skilled nursing stay, Medicare or you?
Dear Toni: My husband recently fell from a ladder, shattered his hip and broke his right leg. After having emergency surgery, Jim is staying in a skilled nursing facility for his rehab to learn how to walk on his repaired hip.
A friend recently had a skilled nursing stay and was billed more than expected because she did not have the right amount of time as an inpatient during her preceding hospital stay. Please explain what I need to know about Medicare, Jim’s skilled nursing care and what I have to pay for a skilled nursing stay. — Terry, Tulsa, Oklahoma
Dear Terry: The Medicare skilled nursing qualification rule is explained on Page 28 of “Medicare & You.” A stay in the hospital does not always mean you are an inpatient and that you qualify for skilled nursing facility care through Medicare Part A. If you do not, you might have to pay 100 percent out of pocket.
The Medicare outpatient observation notice (MOON) rule applies only to original Medicare, not to Medicare Advantage plans.
The Medicare handbook explains this rule: “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.”
You become an inpatient only when a hospital formally admits you as one, after a doctor orders it. You’re still an outpatient if you haven’t been formally admitted, even if you’re getting emergency department services, observation services, outpatient surgery, lab tests or X-rays.
As the handbook advises, “Each day you have to stay, you or your caregiver should always ask the hospital and/or your doctor, a hospital social worker or a patient advocate if you’re an inpatient or an outpatient.” This is key, as it affects what you pay and whether you’ll qualify for Part A coverage in a skilled nursing facility.
If you are on original Medicare and staying in a hospital, be sure you are provided the MOON in written form that is signed and dated, with an oral explanation from the facility no later than 36 hours from the time you begin receiving outpatient observation services.
The first two days of a hospital stay are considered outpatient under the MOON rule. Some beneficiaries may have to pay 100 percent of the skilled nursing stay if they have not been formally admitted as an inpatient with at least a three-day hospital stay and a discharge on the fourth day.
Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.
