Discharging to a skilled nursing facility? Medicare requirements are changing

PROVIDENCE OREGON – During the COVID-19 pandemic, CMS issued a waiver of the three-midnight inpatient requirement for the Medicare Part A coverage of services at a skilled nursing facility. The waiver expires March 11 and impacts patients enrolled in original Medicare. Patients enrolled in Medicare Advantage plans (plans offered by private companies approved by Medicare) remain under the guidelines of their insurers.

Patients and their loved ones often request placement in a skilled nursing facility as their preferred discharge destination during hospital encounters. Understanding eligibility requirements will ease the way of our patients and support realistic discharge expectations. This can reduce confusion that may lead to avoidable inpatient days.

What do providers need to know?

• Medicare only pays for skilling-nursing facility care when patients have a qualifying skilled medical need and a qualifying inpatient hospital stay.
• A qualifying skilled medical need requires daily nursing and therapy to treat, manage, observe and evaluate care. This care can only be safely and effectively performed by licensed professionals or technical personnel.
• There are two types of qualifying inpatient hospital stays:
  • A patient has been admitted to the hospital with an inpatient admission order for at least three midnights in a row.
  • A patient was admitted to a hospital within the past 30 days and the need for a skilled nursing facility is related to the reason for the prior hospitalization. The prior hospitalization needs to have included three midnights following an inpatient admission order.
• Observation services are considered outpatient care and do NOT count towards the three-midnight requirement to cover care at a skilled nursing facility.

Learn more

Care management partners are available to help you understand post-acute care benefits and resources. Please consult with your ministry’s care management team early and often to support timely and effective discharge planning.