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SHINE: Serving the Health Insurance Needs of Everyone

Post-hospitalization skilled nursing facility care: Will Medicare cover your stay?

If you are a Medicare beneficiary, Medicare can pay for up to 100 days of care in a Skilled Nursing Facility (SNF) such as a nursing home. Usually, in order to qualify for Medicare coverage, you must have a qualifying hospital stay of three consecutive days or more (often referred to as the “three midnights rule”) and you must need and receive doctor-ordered skilled care or therapy on a daily basis. However, being in the hospital for three days does not guarantee that Medicare will pay for SNF care. The stay must also be classified as an “inpatient” hospitalization.

Why is this important?

In recent years, some Medicare beneficiaries have been admitted to a hospital for days, if not weeks, at a time, and thought they satisfied the three-day hospitalization requirement. But actually, during that time their hospital classified them as being under “observation status.” When a person stays in a hospital under “observation status,” instead of as an “inpatient,” those days in the hospital will not count as part of the three hospital days they need so that Medicare will cover their care at a Skilled Nursing Facility. Not only does classification as “inpatient” or “observation” status impact whether Medicare will pay for a patient’s SNF stay, but also it can change the amount the patient will pay for the services and medications received while in the hospital.

How do I find out which category applies to my situation?

Fortunately, as of March 8, 2017, hospitals are required to give Medicare patients both oral and written notice when they are categorized as “observation” status patients for 24 hours. The written notice, called the Medicare Outpatient Observation Notice (“MOON”), should be given directly to the patient or the patient’s representative. The notice must be provided no later than 36 hours after observation services are initiated or, if sooner, upon release. The patient or their representative is supposed to sign the notice to confirm receipt and to confirm that he or she understands the notice. Medicare estimates that approximately 1.4 million MOONs will be delivered annually.

Remember: if you go to a skilled nursing facility after an “observation” status hospital stay, Medicare may not pay for your care.

If you are a Medicare beneficiary facing possible SNF care after a hospitalization, you should take the following steps to protect your right to appropriate Medicare coverage:

  • Review any notices you receive from your medical providers, including any MOON-related paperwork.
  • Make sure to ask your doctor or other hospital staff whether you are considered an “inpatient” or whether you are under “observation” status. Be aware that some hospitals change a person’s status during the course of his or her stay, so ask this question multiple times when you are in the hospital.
  • If you think you should be an “inpatient,” speak to your physician, your care manager, and/or other hospital staff about having your classification changed from “observation” to “inpatient.”

The Medicare Advocacy Project (MAP) is devoted to assisting people who may have been wrongfully denied Medicare. If you have questions about your Medicare claims or need legal advice, contact your local MAP office via Greater Boston Legal Services at 1-800-323-3205. For residents of central and western Massachusetts, contact Community Legal Aid at 1-855-252-5342.

The SHINE program, (Serving Health Information Needs of Everyone… on Medicare), provides free, confidential and unbiased health insurance counseling for Medicare beneficiaries. To reach a trained and certified counselor in your area, contact the regional office at 1-800-498-4232 or 413-773-5555 or contact your local council on aging.