The Observation Hour Sets the Facility Bill: Check the Stay Status Before You Accept a Bed

The first cost question for a skilled nursing facility is not the daily rate. It is whether the hospital stay your parent just had counts as inpatient. Original Medicare covers a skilled nursing facility stay only after a qualifying inpatient stay of three inpatient days, and time spent in observation status does not count toward that requirement, even when the room looks the same from the hallway. (Medicare.gov, Skilled Nursing Facility Care.)

Local option: New Plan Care gives families in the St. Louis area in-home help so a parent can stay home: companionship, help with bathing and dressing, meals, and overnight care. Call (314) 405-0887.

Ask for the status in writing

Before you accept a facility bed, ask the hospital case manager or discharge planner one question: is my parent admitted as an inpatient, or in observation status? Ask for the answer in writing, or ask that it be noted in the discharge paperwork. If your parent was in observation for a long stretch, Medicare requires the hospital to give a written notice about observation status, the Medicare Outpatient Observation Notice, and that notice is a page to keep in the folder. (CMS, Medicare Outpatient Observation Notice.)

Count the days the way the bill counts them

Under Original Medicare, the first 20 days of a covered skilled nursing stay in a benefit period have no daily coinsurance. From day 21 through day 100 there is a daily coinsurance amount, which Medicare sets each year. After day 100, Medicare pays nothing for that benefit period. A benefit period starts with the first day of care and ends after your parent has been out of the hospital and any skilled facility for 60 days in a row. (Medicare.gov, Skilled Nursing Facility Care.) Write the admission date on the front of the folder and count forward from it. Check the day count on each statement against your own count, and call the billing office if they do not match.

Skilled care has to be daily and medically necessary for Medicare to cover the stay. A stay that provides only custodial help, such as meals, bathing, and supervision, is generally not covered under the skilled benefit. (Medicare.gov, Skilled Nursing Facility Care.) Ask the facility how it describes the care your parent needs, and ask what happens if the care level changes during the stay.

If there is a Medicare Advantage plan

If your parent is in a Medicare Advantage plan instead of Original Medicare, the facility rules come from that plan. Check whether the plan requires approval before admission, whether the facility is in the plan network, and what the plan charges for the days you expect to use. Plans must describe these terms in their plan documents, and CMS publishes the plan rules that apply. (CMS, Medicare Advantage.) Do not assume the Original Medicare day count applies to a Medicare Advantage stay.

If your parent has Medicaid as well, or a supplemental policy, those can change what is owed on the coinsurance days. Ask each payer which of its rules apply to this facility stay. The Sources page lists the public pages this desk uses for these checks.

What to bring to the call

Write down the hospital stay start date, the admission type, the facility name and whether it is in network, the plan name on the card, and the questions above. Ask the facility for its daily rate for the coinsurance days and whether it accepts the plan. The total you eventually receive is built from these answers, not from the brochure.