Although Medicare does cover care provided in a Skilled Nursing Facility (SNF), there are requirements before this coverage will be effective. Most notably, is Medicare’s 3-day Rule. Make sure you understand all of the conditions that need to be met for Medicare to cover a stay at a SNF.
Skilled Nursing Facilities Conditions for Coverage
Medicare Part A (Hospital Insurance) covers skilled nursing care provided in a SNF in certain situations for a limited time (on a short-term basis) if you have
- Part A and have days left in your benefit period to use it,
- your doctor has decided that you need daily skilled care (It must be given by, or under the supervision of, skilled nursing or therapy staff),
- You get these skilled services in a SNF that’s certified by Medicare.
- You need these skilled services for a medical condition that’s either:
- A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay, even if it wasn’t the reason you were admitted to the hospital.
- A condition that started while you were getting care in the SNF for a hospital-related medical condition (for example, if you develop an infection that requires IV antibiotics while you’re getting SNF care)
- You have a qualifying hospital stay.
This last requirement, a “qualifying hospital stay” is referring to the 3-Day Rule. The specific requirements to satisfy the 3-Day Rule are below.
What is the 3-Day Rule?
To qualify for Skilled Nursing Facility (SNF) extended care services coverage, Medicare beneficiaries must meet the “3-day rule” before SNF admission. The 3-day rule requires the beneficiary to have a medically necessary 3-day-consecutive inpatient hospital stay before the SNF, and does not include the day of discharge, or any pre-admission time spent in the emergency room (ER) or in outpatient observation, in the 3-day count.
SNF extended care services are an extension of care that a beneficiary needs after hospital discharge or within 30 days of their hospital stay (unless admitting them within 30 days is medically inappropriate). Hospitals should correctly communicate to SNFs and beneficiaries (and/or their representatives) the number of inpatient days, so all parties fully understand the potential payment liability.
Example:
A beneficiary went to a hospital emergency room (ER) after falling in her home and a physician admitted her to the hospital on April 16. On April 18, the hospital discharged her to SNF extended care services. In this case, the beneficiary did not stay in the hospital long enough to satisfy the 3-day rule. Hospitals can count the admission day (April 16), but not the discharge day (April 18).
SNF staff gave the beneficiary and their representative the Important Message from Medicare (IM), which informs them of their right to appeal the discharge, and proactively told the beneficiary and her representative she does not qualify for SNF coverage because she did not stay in the hospital 3 days not counting discharge. Medicare rules allow SNF stay coverage when the beneficiary’s hospital stay meets the 3-day rule. Since the beneficiary’s inpatient stay was 2 days, if she accepts the SNF admission, she must pay the extended care services claim out-of-pocket unless she has other coverage.
Many Medicare Advantage plans are available that waive the 3 day requirement. Make sure you review those plans with your client.
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