TONI SAYS: Qualifying for skilled nursing can be stressful

By Toni King

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.

Is there anything I should be aware of regarding skilled nursing since she disenrolled last Medicare Annual Enrollment from a Medicare Advantage HMO to her new Medicare Supplement?

I cannot remember specifics about a Medicare rule you once wrote about 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. Thanks, Tom from Las Vegas, NV

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 and is explained below:

  • 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 that may result in an overnight stay in the hospital which cannot qualify as a “formal inpatient admission” which is extremely important 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.

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 where Medicare will cover the cost:

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 Skilled Nursing Facility 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 SNF stay is covered.

Call the Toni Says Medicare hotline at (832) 519-8664 or email [email protected] for assistance with Medicare issues. Toni’s books are available at with a bundle discount for Toni Says readers.