The Medicare 3-day rule relates to Skilled Nursing Facility (SNF) care. We will look into what SNF care is, how the 3-day rule relates to the requirements, and what happens if this rule is not met.
What Is SNF Care?
SNF care takes place after you are hospitalized. These facilities provide a high level of patient supervision by qualified healthcare professionals.
It’s covered under Medicare Part A. These are costs you will pay if you stay in a SNF:
- $0 for the first 20 days of a benefit period
- $185.50 daily coinsurance for 21 to 100 days of a benefit period
- Everything after day 100 comes out of pocket
What Are the Requirements for SNF Care?
You cannot get SNF care unless a doctor has determined that you need it because your condition warrants skilled nursing staff supervision.
And, you must have stayed in a hospital for three consecutive calendar days. Pre-admission and discharge days do not count as qualifying inpatient hospital stays. This is the 3-day rule.
You must also have Medicare Part A, with days left in your benefit period. Then, as for your condition itself, it must have been a condition that was treated during your stay. That condition may not be what you first went into the hospital for. The condition may have also started while in the process of getting SNF care.
What Happens if the 3-Day Rule Isn’t Met?
If you haven’t been in the hospital for three consecutive days (not counting pre-admission or discharge) as an inpatient, Medicare will not cover you. If you’ve only been in the hospital for two days and you were discharged on the third, that doesn’t count – you’ll have to pay everything.
Hospitals are to give reliable hospital stay information to policyholders and SNFs because this keeps all parties informed and prevents chances of improper payment.
Improper payment involves using Medicare to pay for SNF services despite the patient not meeting the 3-day rule. The consequence of improper payment falls on who was deemed to be at fault. If it is the provider’s fault, then the insurer collects overpayment from the SNF. If it’s the policyholder’s fault, then Medicare gets overpayment recovery from the Medicare policyholder (unless that has a substantial adverse effect on the policyholder’s finances; then that recovery payment is waived). If both policyholder and provider are not at fault for improper payment, then the Center for Medicare and Medicaid Services will cover the SNF care.
Questions? Concerns? Let Us Help
Don’t let any question go without an answer – it can be the difference between knowing what needs to be done in order to get affordable treatment and being shocked when finding out that you may have to pay for everything out-of-pocket. At Turning 65 Solutions, if you need us, we’re always ready to help you sort through anything related to Medicare. Call us on the phone at (830) 217-6711, and you can also send an email to ron@t65s.com.