10. Delivery of the Medicare Outpatient Observation Notice (MOON) is required as of March 8, 2017. The NOTICE Act which was signed into law on August 6, 2015 required implementation by August 6, 2016 but the Centers for Medicare and Medicaid Services used their rule-making authority to extend that deadline.
9. CMS released Manual instructions via Transmittal 3695 (Change Request 9935) for the MOON on January 20, 2017 which go into detail about delivery of the MOON including when the patient is not competent to comprehend notice. That transmittal indicated an implementation date of February 21, 2017 but that date refers to implementation of the instructions and did not change the March 8 deadline.
8. The MOON must be provided to outpatients receiving Observation services whose care is eligible to be financed by Medicare, including patients with traditional Medicare, Medicare Advantage, Medicare as a secondary payer and even patients who are eligible for Medicare part B but chose not to purchase it.
7. The MOON is required for patients who receive more than 24 hours of Observation services and must be delivered before the 36th hour of Observation but can be delivered to patients who receive less than 24 hours of Observation service. It should not be given to patients who are receiving outpatient services without Observation. Delivery should be deferred if the patient is overwhelmed or unable to comprehend the explanation. If a patient receives Observation services for over 24 hours and is subsequently admitted as inpatient or discharged, they still must receive the MOON. If a state has a law about notification of Observation services with different requirements as to time and eligible patients, the MOON requirements must still be met for Medicare-eligible patients.
6. The MOON notifies patients that their hospital stay is covered by Part B and they will be responsible for applicable copayments and deductibles. This will confuse patients with Medicare Advantage since their stay is covered by Part C and they do not have the same financial obligations. It also notes that patients generally pay a copayment for each service they receive. That is also misleading as most outpatient stays with observation services will fall into the Comprehensive Ambulatory Payment Classification (C-APC) established in 2016 for Observation. C-APCs pay a fixed amount for all services provided during the stay, regardless of the number or type of services, and the patient's copayment is based on that single approved payment.
5. The MOON notifies patients that they are responsible for the cost of self-administered medications which are not covered by part B. The Office of the Inspector General of the Department of Health and Human Services issued a memorandum in October, 2015 allowing hospitals to waive these costs. If a hospital does waive these charges, they can indicate such in the "additional information" section of the MOON.
4. The MOON notifies patients that the days spent in the hospital as outpatient do not count to the inpatient days necessary to qualify for a paid skilled nursing facility (SNF) stay. Medicare regulations require a patient to have an inpatient admission that lasts three or more days, not counting the day of discharge, to qualify for Part A coverage of their SNF stay. Additionally, they must also require skilled care to qualify for Part A SNF payment.
3. The content and format of the MOON may not be altered in any way except to complete the two free text areas of the MOON; one to add the required reason that the patient is not an inpatient and one to add any additional information such as a contact number for questions or information about participation in any programs such as Accountable Care Organizations that allow waiving the inpatient three-day stay requirement for a covered SNF stay.
2. The hospital must indicate on the MOON the specific reason the patient is not being admitted as inpatient. CMS has not (as of the date of this publication) provided clarity on whether checkboxes are allowed in this section and whether a specific clinical reason is needed which includes details of their illness or whether a statement about expected length of stay is sufficient.
1. The patient must be given an oral explanation of the MOON and the hospital must document that the oral explanation was provided. This oral explanation can be provided via a video recording as long as someone is available to answer questions. If the individual receiving the notice is unable to read its written contents and/or comprehend the required oral explanation, hospitals and CAHs must employ their usual procedures to ensure notice comprehension consistent with section 1557 of the Affordable Care Act, Title VI of the Civil Rights Act of 1964 and section 504 of the Rehabilitation Act of1973.
Lift Off! Patients are asked to sign, date and time the MOON to acknowledge that the information was provided to them and a copy of the completed MOON must be given to the patient. If a patient refuses to sign, that should be noted on the form by the person delivering the MOON and a copy left with the patient. Patients given a MOON do not have immediate appeal rights with the Quality Improvement Organizations to object to being placed in the hospital as outpatient with Observation services.
Ronald Hirsch, MD, FACP, CHCQM
Vice President, Regulations and Education
R1 RCM and Physician Advisory Services
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