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 Important Resources


 Residents and Families


​Has your loved one been impacted by observation stays?

Share your story with us. Please be sure to fill out the release form.


 AHCA/NCAL Members


​Have observation stays impacted your residents and patients?

Contact Us and help us close this observation stay loophole.

Please be sure to fill out the release form.



 Press Releases


Skilled nursing care centers serve our most vulnerable citizens – frail elders and those with disabilities who need complex medical, rehabilitative, and restorative care, 24 hours a day, 7 days a week.

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) is concerned that Medicare beneficiaries’ access to skilled nursing care is being constrained by the increased use of observation stays, which prevents patients from reaching the three-day stay threshold for Medicare coverage.

Senators Sherrod Brown (D-OH), Susan Collins (R-ME), Bill Nelson (D-FL), Shelley Moore Capito (R-WV) and Representatives Joe Courtney (D-CT-2) and Joe Heck (R-NV-3) share our concern and have introduced the  Improving Access to Medicare Coverage Act of 2015 (S. 843/H.R. 1571) to address these situations. The Improving Access to Medicare Coverage Act of 2015 would deem an individual receiving outpatient's observation services in a hospital to be an in-patient with respect to the Medicare three-day stay requirement.

Learn more about observation staysand the impact​ on Medicare beneficiaries.

Call for Stories – Observation Stays Issue

AHCA/NCAL continues to keep the observation stays issue one of its top advocacy and outreach priorities. Our efforts include working with the Observation Stays Coalition to support the Improving Access to Medicare Coverage Act, which has been introduced in previous Congresses and will be introduced again this Congress. This legislation ensures observation stays count toward the Medicare-required three-day hospital stay, and the Coalition continues to connect with key members of Congress to support it. Last year, you helped us by submitting stories that put a face on the financial and emotional impact of this issue. That stories document is on our website here and has been incredibly valuable in sharing with members of Congress. To boost our advocacy efforts, we need your help again!    

We are looking for more powerful stories to add to what we already have. If you have a recent beneficiary story in mind, please email and the following for consideration:

1. No more than seven (7) sentences that captures the beneficiary’s financial and emotional impact. Please include an out-of-pocket dollar amount. See examples here.

2. The name AND written consent of the beneficiary. The authorization form here gives AHCA/NCAL permission to use the individual’s name and story.

3. The state AND city where the story took place. We would like stories from each state to take to the Hill and to others to show the importance of this matter. 

We will also accept a recent local news story that identified the beneficiary. In this case, we do not need a consent form since the beneficiary gave the news outlet consent to publish their story. We will simply give the news outlet credit IF we decide to highlight the story.

For more information on this issue, visit the observation stays page on

NOTICE Act MOON and Form Instructions Now Available
Dana Halvorson

According to the Centers for Medicare and Medicaid Services (CMS), the finalized Medicare Outpatient Observation Notice (MOON) and form instructions are now available. They can be found here. The MOON is a standardized notice to inform beneficiaries (including Medicare health plan enrollees) that they are an outpatient receiving observation services and are not an inpatient of the hospital or critical access hospital (CAH).

Outpatient status affects a patient’s ability to receive Medicare coverage for post-acute care in a skilled nursing center. The MOON is mandated by the Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) enacted on August 6, 2015.

AHCA/NCAL supports the NOTICE Act law. The NOTICE Act requires all hospitals and CAHs to provide written and oral notification under specified guidelines. Hospitals and CAHs must begin using the MOON no later than March 8, 2017. Manual instructions will be made available in the coming weeks. A fact sheet on the MOON is available here.

Comment Period Open on the Revised Medicare Outpatient Observation Notice
Dana Halvorson

The Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act requires hospitals to notify Medicare beneficiaries of their outpatient status within 36 hours. Outpatient status affects a patient’s ability to receive Medicare coverage for post-acute care in a skilled nursing center. AHCA/NCAL supports the NOTICE Act law.

On August 2, 2016, the final rule from the Centers for Medicare and Medicaid Services (CMS) on the implementation of the NOTICE Act was released. A brief summary of the NOTICE Act section of the CMS final rule put together by Hancock, Daniel, Johnson & Nagle, P.C., is available here. The NOTICE Act had technically required that Medicare eligible patients receive a notice of their outpatient observation status starting on August 6, 2016. However, the CMS final rule notes that the Medicare Outpatient Observation Notice (MOON) has not yet been approved for use and is thus delaying official implementation of the law until Fall 2016.

According to an August 16, 2016, CMS email notice, beginning August 2, 2016, the public has 30 days to comment on the revised MOON under the Paperwork Reduction Act (PRA). The information collection request will be submitted to the Office of Management and Budget (OMB) for review and approval. The information collection requirements are not effective until approved under a valid OMB control number.

CMS expects final PRA approval of the MOON around the time the implementing regulations are effective. It also expects hospitals and CAHs to begin using the MOON no later than 90 calendar days from the date of final approval of the MOON by OMB. The draft MOON subject to the 30 day comment period, along with instructions on how to submit comments, can be found here. The comment period ends September 1, 2016. According to the CMS email, the Agency will provide additional information related to MOON implementation on its Beneficiary Notices Initiative webpage when the MOON is approved and in a Health Plan Management System memorandum to Medicare Advantage plans.