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Medicare Outpatient Observation Notice (MOON)
Centers for Medicare & Medicaid Services · source: Form CMS-10611-MOON, English (2026), expires 02/28/2029 · 9 critical facts of 15
Placeholders in the agency's template were filled with made-up values; see the notice's source file in the repo.
Rewrites
Haiku, grade 6: 8 of 9 critical facts kept · grade 6.6
What the judge found lost or changed
- changed The Part B copayments or coinsurance may be lower or higher than the Part A inpatient deductible.
The letter: “Your Part B copayments/coinsurance may be lower or higher than the Part A inpatient deductible” · The rewrite: “These costs may be more or less than the costs of an inpatient stay under Medicare Part A.”
The rewrite
Dear Ruth Delgado,
This paper is about your stay at Maury Regional Hospital, 1224 Trotwood Avenue, Columbia, TN 38401.
**Your hospital status is "outpatient observation."** This means you are not admitted to the hospital as an inpatient. You are still being watched and checked by the hospital.
**Why are you in observation?** Your doctor wants to keep you while your test results for chest pain come back. Your doctor has not yet written an order to admit you as an inpatient.
**How is this billed?** Because you are an outpatient, your stay is paid under Medicare Part B. You will pay a copay or coinsurance for each outpatient service you get. These costs may be more or less than the costs of an inpatient stay under Medicare Part A. The hospital can tell you more about billing.
**Important to know after you leave:** If you go to a skilled nursing facility (a place that gives nursing care after a hospital stay), Medicare may not pay for it.
**Questions?** You can call Medicare at 1-800-MEDICARE (1-800-633-4227). If you use a TTY (a phone for people who are deaf or hard of hearing), call 1-877-486-2048.
**Your rights:** You have the right to get Medicare information in a format you can use, such as large print, braille, or audio. You also have the right to file a complaint if you think you were treated unfairly because of who you are. To learn more, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice or call 1-800-MEDICARE. TTY users can call 1-877-486-2048.
**Please sign this paper** to show that you got it and understand it.
Signature of patient or representative: ____________________
Date: ____________________
Sonnet, grade 6: 8 of 9 critical facts kept · grade 7.2
What the judge found lost or changed
- changed The patient will have a copayment or coinsurance for each outpatient hospital service they get.
The letter: “you’ll have a copayment/coinsurance for each outpatient hospital service you get” · The rewrite: “You will likely have to pay a share of the cost for each service you get. This is called a copayment or coinsurance.”
The rewrite
**Maury Regional Hospital**
1224 Trotwood Avenue, Columbia, TN 38401
**Notice for Ruth Delgado: You Are Getting "Observation" Care**
**Important:** You are in the hospital, but you are **not** an inpatient. The hospital calls you an **outpatient** who is getting **observation services**. This means the hospital is watching you and checking on your health.
**Why you are not an inpatient**
Your doctor wants to keep you here while the results of your chest pain tests come back. Your doctor has not yet written an order to admit you as an inpatient.
**What this means for your bill**
- Medicare Part B will pay for your stay. It will not be paid by Medicare Part A.
- You will likely have to pay a share of the cost for each service you get. This is called a copayment or coinsurance.
- What you pay under Part B could be less than the Part A inpatient deductible, or it could be more. The hospital can tell you more about your bill.
**Important for later**
When you leave the hospital, you may need care in a skilled nursing facility. Medicare may not pay for that care because you were an outpatient.
**Questions?**
Call Medicare at 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.
**Please sign**
Sign below to show that you got this notice and understand it.
Signature of patient or representative: ____________
Date: ____________
**Your rights**
- You can get Medicare information in a way that works for you, such as large print, braille, or audio.
- You can file a complaint if you feel you were treated unfairly because of who you are.
- To learn more, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice. You can also call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.
Opus, grade 6: 7 of 9 critical facts kept · grade 6.6
What the judge found lost or changed
- changed The patient will have a copayment or coinsurance for each outpatient hospital service they get.
The letter: “you’ll have a copayment/coinsurance for each outpatient hospital service you get” · The rewrite: “With Part B, you may have to pay part of the cost **for each service** you get.” - changed After leaving the hospital, Medicare may not pay if the patient goes to a skilled nursing facility.
The letter: “After you leave the hospital, Medicare may not pay if you go to a skilled nursing facility” · The rewrite: “After you leave the hospital, you may need extra care at a **nursing home** or **rehab center**. If so, Medicare **may not pay** for it.”
The rewrite
**Patient name:** Ruth Delgado
**Hospital name:** Maury Regional Hospital
**Hospital address:** 1224 Trotwood Avenue, Columbia, TN 38401
## Medicare Notice: You Are in the Hospital for "Observation"
**Please read this. It is important.**
You are getting this letter because the hospital is **watching you closely** to see how you are doing. This is called **"observation."**
Even if you stay overnight, you are **not admitted** to the hospital. That means you are an **outpatient**, not an **inpatient**.
### What this means for your bills
- Your stay will be paid by **Medicare Part B**, not Medicare Part A.
- With Part B, you may have to pay part of the cost **for each service** you get. This could be for each test, medicine, or doctor visit.
- The total you pay might be **more or less** than what you would pay if you were admitted. Ask the hospital if you have questions about your bill.
- After you leave the hospital, you may need extra care at a **nursing home** or **rehab center**. If so, Medicare **may not pay** for it.
### Why you are not admitted
Your doctor wants to watch you while you wait for the results of tests for your **chest pain**. Your doctor has **not** written an order to admit you to the hospital.
## Questions?
To learn more about what Medicare pays for, call **1-800-MEDICARE** (1-800-633-4227).
If you are deaf or hard of hearing and use TTY, call **1-877-486-2048**.
**Please sign below.** Your signature shows that you got this letter and understand it.
Signature of patient or person signing for the patient: ____________ Date: ____________
## Your Rights
You can get Medicare information in a form that is easier for you to use, such as **large print**, **braille**, or **audio**.
If you feel you were treated unfairly because of who you are, you can **make a complaint**.
To learn more, visit **Medicare.gov/about-us/accessibility-nondiscrimination-notice** or call **1-800-MEDICARE** (1-800-633-4227). TTY users can call **1-877-486-2048**.
Sonnet, grade 4: 7 of 9 critical facts kept · grade 5.9
What the judge found lost or changed
- changed The hospital stay will be billed to Medicare Part B instead of Part A.
The letter: “your hospital stay will be billed to Medicare Part B instead of Part A” · The rewrite: “Medicare Part B will help pay for your stay. Medicare Part A will not.” - changed For more information about Medicare coverage, call 1-800-MEDICARE (1-800-633-4227).
The letter: “For more information about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227)” · The rewrite: “Call Medicare at 1-800-MEDICARE (1-800-633-4227).”
The rewrite
**Maury Regional Hospital**
1224 Trotwood Avenue, Columbia, TN 38401
**Patient:** Ruth Delgado
**Medicare Notice: You Are Being Watched in the Hospital, but You Are Not Admitted**
Dear Ms. Delgado,
Please read this note. It is important.
**What is your status?**
You are in the hospital. But the hospital has not "admitted" you. Your status is called "outpatient." You are getting "observation services." This means the doctors and nurses are watching you and checking on you.
**Why are you not admitted?**
Your doctor wants to keep you here while you wait for test results. The tests are for your chest pain. Your doctor has not yet written an order to admit you.
**What this means for your money**
- Medicare Part B will help pay for your stay. Medicare Part A will not.
- You will have to pay part of the cost for each service you get at the hospital. This is called a copay or coinsurance.
- What you pay could be less or more than the Part A hospital deductible. Ask the hospital if you want to know more about your bills.
- After you leave the hospital, you may need to stay in a skilled nursing facility. This is a place that gives nursing care and therapy. Medicare may not pay for it.
**Do you have questions?**
Call Medicare at 1-800-MEDICARE (1-800-633-4227). If you use a TTY phone, call 1-877-486-2048.
**Please sign**
Sign below to show that you got this notice and understand it.
Signature of patient or helper: ______________________
Date: ______________________
**Your rights**
- You can ask for Medicare papers in other forms. These include large print, braille, or audio.
- You can make a complaint if you think someone treated you unfairly. For help, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice. Or call 1-800-MEDICARE (1-800-633-4227). If you use a TTY phone, call 1-877-486-2048.
Sonnet, grade 8: 9 of 9 critical facts kept · grade 7.0
The judge found nothing lost.
The rewrite
**Maury Regional Hospital**
1224 Trotwood Avenue, Columbia, TN 38401
**Patient:** Ruth Delgado
## Notice About Your Hospital Stay (Medicare)
**Please read this. It is important.**
The hospital has placed you in "observation" status. This means you are a hospital **outpatient**. You are **not** an inpatient right now.
### Why you are not an inpatient
Your doctor wants to keep watching you while your test results for chest pain come back. Your doctor has not written an order to admit you as an inpatient.
### What this means for you
- **Medicare Part B will cover your stay, not Part A.** Part B is the part of Medicare that covers outpatient care.
- **You will have to pay a share of the cost.** You will pay a copayment or coinsurance for each outpatient service you get in the hospital.
- **Your costs could be lower or higher** than the Part A inpatient deductible. Ask the hospital for more details about your bill.
- **Skilled nursing care may not be covered.** If you need to go to a skilled nursing facility after you leave the hospital, Medicare may not pay for it.
### Questions?
Call Medicare at **1-800-MEDICARE (1-800-633-4227)**. If you use a TTY, call **1-877-486-2048**.
### Please sign
Sign below to show that you got this notice and understand it.
Signature of patient or representative: ____________________
Date: ____________
### Your rights
- You can ask for Medicare information in a format that works for you, such as large print, braille, or audio.
- You can file a complaint if you think you were treated unfairly because of who you are.
To learn more, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Sonnet, grade 6, 'keep everything' prompt: 9 of 9 critical facts kept · grade 8.2
The judge found nothing lost.
The rewrite
**Medicare Outpatient Observation Notice**
**To:** Ruth Delgado
**From:** Maury Regional Hospital, 1224 Trotwood Avenue, Columbia, TN 38401
**Please read this. It is important.**
You are getting this notice because the hospital has you listed as an "outpatient receiving observation services." You are not listed as an "inpatient."
**What this means for you**
- The hospital will bill your stay to Medicare Part B. It will not bill Medicare Part A.
- Part B covers your observation stay. You will have to pay a copayment or coinsurance for each outpatient hospital service you get.
- What you pay under Part B could be lower or higher than the Part A inpatient deductible. The hospital can give you more facts about billing.
- After you leave the hospital, Medicare may not pay if you go to a skilled nursing facility.
**Why you are not an inpatient**
Your doctor is keeping you in the hospital for observation while the results of your chest pain tests come back. Your doctor has not written an order to admit you as an inpatient.
**Questions?**
To learn more about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.
**Please sign**
Sign below to show that you got this notice and understood it.
Signature of patient or representative: ____________
Date: ____________
**Your rights**
- You have the right to get Medicare information in a way that works for you. This includes large print, braille, or audio.
- You have the right to file a complaint if you feel you were treated unfairly because of who you are (discrimination).
- To learn more, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice. You can also call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.
Rewrite tool (Sonnet, grade 6): 9 of 9 critical facts kept · grade 7.8
The judge found nothing lost.
The rewrite
**Patient:** Ruth Delgado
**Hospital:** Maury Regional Hospital
**Address:** 1224 Trotwood Avenue, Columbia, TN 38401
# Medicare Outpatient Observation Notice
## Your hospital status
**Important!** You are getting this letter because of your hospital status. You are an **outpatient** getting **observation services**. You are **not** an inpatient.
## Why you are not an inpatient
Your doctor is keeping you here to watch you while the test results for your chest pain come back. Your doctor has not written an order to admit you as an inpatient.
## What this means for your bills
- Your hospital stay will be billed to Medicare **Part B**. It will not be billed to Part A.
- As an outpatient, your observation stay is covered under Part B.
- You will pay a copayment or coinsurance for each outpatient hospital service you get.
- Your Part B copayments or coinsurance may be lower or higher than the Part A inpatient deductible.
- Your hospital can give you more information about billing. Just ask.
## If you go to a skilled nursing facility
After you leave the hospital, Medicare may not pay if you go to a skilled nursing facility.
## Questions?
Call Medicare to learn more about your coverage.
- Phone: **1-800-MEDICARE (1-800-633-4227)**
- TTY users: **1-877-486-2048**
## Please sign
Sign below to show that you got this letter and understood it.
Signature of patient or representative: ____________
Date: ____________
## Your rights
- You have the right to get Medicare information in a way that works for you. This includes large print, braille, or audio.
- You have the right to file a complaint if you feel you were treated unfairly because of who you are (discrimination).
To learn more, you can:
- Visit **Medicare.gov/about-us/accessibility-nondiscrimination-notice**
- Or call **1-800-MEDICARE (1-800-633-4227)**
- TTY users: **1-877-486-2048**
The original letter
Highlighted: the passages behind the 9 critical facts.
Patient name: Ruth Delgado
Hospital name: Maury Regional Hospital
Hospital address: 1224 Trotwood Avenue, Columbia, TN 38401
## Medicare Outpatient Observation Notice
Important! You’re getting this notice because your hospital status is “hospital outpatient receiving observation services,” not “hospital inpatient.”
This means your hospital stay will be billed to Medicare Part B instead of Part A.
- When you’re a hospital outpatient, your observation stay is covered under Medicare Part B. This means you’ll have a copayment/coinsurance for each outpatient hospital service you get.
- Your Part B copayments/coinsurance may be lower or higher than the Part A inpatient deductible. Your hospital can give you more information about billing.
- After you leave the hospital, Medicare may not pay if you go to a skilled nursing facility.
You aren’t an inpatient because: your doctor is keeping you for observation while test results for your chest pain come back, and has not written an order to admit you as an inpatient.
## Questions?
For more information about your Medicare coverage, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Sign below to show you received and understood this notice.
Signature of patient or representative: ____________ Date: ____________
You have the right to get Medicare information in an accessible format, like large print, braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.