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Understanding Medicare’s rules on skilled nursing coverage

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?

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. — Tom, Las Vegas

Dear 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 care.

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, here’s how this rule applies to your mother’s skilled nursing care:

■ 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 in which 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 an outpatient. When under observation as an outpatient for more than 24 hours, you must receive a Medicare Outpatient Observation Notice.

Under Part A for a skilled nursing stay, Medicare will only cover semiprivate rooms with meals, skilled nursing and therapy services after a minimum three-day medically necessary inpatient hospital stay.

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 info@tonisays.com or call 832-519-8664.

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