Two Midnight Rule and Three Day stay for Medicare

I have been asked for clarification on the "Two Midnight" rule and the requirement for a three-day inpatient stay to qualify for a skilled nursing facility.  These are actually two different rules.

For a stay in a skilled nursing care facility to be paid by Medicare Part A, the enrollee must have an inpatient stay of three-consecutive days. This three days does not include the day of discharge or any time spent under outpatient observation. A patient may be in the hospital and not realize that they have not been admitted as an “inpatient.” 

 The “two-midnight rule” originally adopted by CMS in 2013 (and revised in 2016) provides a benchmark for medical providers to determine if it is appropriate to move a patient from “observation” to “admitted” status for Medicare purposes. In general, the rule provides that payment under Part A is appropriate if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supported that reasonable expectation. The rule also provides flexibility to the provider, but states that services expected to last less than “two midnights” are generally not appropriate for coverage under Part A.

Once it is determined that a hospital stay is eligible for Part A coverage (i.e., the patient is admitted as in inpatient), the stay must cover three consecutive days in order for Part A to cover a stay in a skilled nursing facility. 

For more information about Medicare rules or to get help on your coverage, you can contact Alta Vista Benefits at 614-889-0934.