Medicare’s open enrollment period is in full swing and can be quite confusing. Using the services of a Medicare insurance specialist can make all the difference in choosing the right plan for the specific needs of each person enrolling.

Once enrolled in the plan that is best for you, understanding the Medicare’s 3-Day Rule for any needed skilled nursing facility stays is very important.

Medical needs are constantly changing for Medicare-eligible seniors. Sometimes care requires a simple doctor’s visit. Other times an individual may need to be rushed to the hospital with the potential for a prolonged stay. Those who need continued care at a skilled nursing facility (SNF) after being discharged from the hospital may find navigating the health-care maze of rules extremely confusing and challenging.

Medicare’s 3-Day Rule

Many seniors on Medicare understand that Medicare Part A is for hospitalization and Part B is related to insurance coverage.  So where does a skilled nursing facility land?  Medicare’s 3-Day rule relates to getting care in a SNF. Medicare Part A will cover care at a SNF only if the individual is first admitted to the hospital for three days. The key word here is admitted.

When an individual on Medicare gets to the hospital, they are assigned as either admitted (in patient) or under observation.  This wording makes all the difference when dealing with the three-day rule. Medicare Part A will cover the SNF after the three-day qualifying period. Part B does not.

The reason the wording is so important is that those who are under observation are classified as outpatient, which is covered under Medicare Part B. Again, Part B will not cover any portion of a SNF stay.

The rule gets trickier when looking at how the three days are counted. The individual must be assigned as admitted to the hospital for three or more consecutive days, and those three days do not count the day of discharge or any pre-admission time they may spend in an emergency room or under outpatient observation.

Some argue that this scenario is an issue of technicality. Typically, an individual is assigned as under observation when it is determined that the condition will only require a hospital stay less than 48 hours. The problem is when someone is in the hospital for longer than those 48 hours but is still classified as under observation.

For those who qualify, the payment structure with Part A coverage breaks down into three sections if the doctors and therapists determine that progress is being made by the patient:

• The patient pays nothing for days 1-20.
• The patient pays a daily co-insurance premium of $200 (2023) for days 21-100.
• The patient pays all costs if they are in a SNF longer than 100 days.

For those who do not qualify for coverage because they were assigned as under observation will be responsible for all costs from day one if they need care at a SNF. 

Improving Access to Medicare Coverage Act of 2023

On Aug. 4, 2023, U.S. House lawmakers introduced the bipartisan Improving Access to Medicare Coverage Act of 2023. It is aimed at fixing what its sponsors called an “arbitrary Medicare policy that excludes coverage of skilled nursing care for certain patients, resulting in exorbitant and unexpected out-of-pocket costs.” Rep. Joe Courtney (D-CT) and co-sponsors said in a statement, “Under outdated Medicare rules, patients who receive hospital care on ‘observation status’ do not qualify for the benefit of skilled nursing care, even if their hospital stay lasts longer than three days and even if their care team prescribes it.”

The reintroduced bill would apply days spent in the hospital under observation status toward the three-day qualifying hospital stay requirement. Although the Improving Access to Medicare Coverage Act would not completely eliminate the three-day stay requirement, it would be an important step toward addressing it.

Enlisting the help of a Senior Housing Advisor

If after a hospital or SNF stay, it is determined that a move to assisted living is needed to access care that can’t be provided at home, enlisting the help of a Senior Housing Advisor can reduce the overwhelming options in senior housing. Often discharged patients find they have very little time, sometimes only days, to find a community. Senior Housing Advisors know the communities, what services and care they offer and can quickly assist families in finding the best possible solution. Give me a call if I can help.

— By Adrienne Miller, Forever Care Services Chief Care Officer

www.forevercareservices.com

206-383-2001