Three-Day Prior Hospitalization Requirement for Skilled Nursing Facility (SNF) Services

Published 01/03/2020

Post-hospital extended care services furnished to inpatients of a skilled nursing facility (SNF) are a covered Medicare benefit. However, certain requirements must be met for these services to be covered by Medicare. The beneficiary must have been an inpatient of a hospital for a medically necessary stay of at least three (3) consecutive calendar days. Time spent in observation or in the emergency room prior to (or in lieu of) an inpatient admission to the hospital does not count toward the three-day qualifying inpatient hospital stay, as a person who appears at a hospital's emergency room seeking examination or treatment or is placed on observation has not been admitted to the hospital as an inpatient. Instead, the person receives outpatient services. For purposes of the SNF benefit's qualifying hospital stay requirement, inpatient status commences with the calendar day of hospital admission.

SNF services represent an extension of care for a condition for which the individual received inpatient hospital services. To be covered, the extended care services must have been for the treatment of a condition for which the beneficiary was receiving inpatient hospital services, or a condition which arose while in the SNF for treatment of a condition for which the beneficiary was previously hospitalized. In this context, the applicable hospital condition need not have been the principal diagnosis that actually precipitated the beneficiary's admission to the hospital, but could be any one of the conditions present during the qualifying hospital stay.

If the beneficiary is not immediately admitted to a SNF following a three-day qualifying hospital stay, extended care services must be initiated within 30 days after discharge from a hospital stay that included at least three consecutive days of medically necessary inpatient hospital services. The 30-day period begins on the day following actual discharge from the hospital and continues until the individual is admitted to a participating SNF, and requires and receives a covered level of care. Thus, an individual who is admitted to a SNF within 30 days after discharge from a hospital, but does not require a covered level of care until more than 30 days after such discharge, does not meet the 30-day requirement.

In certain limited circumstances the 30-day period may be extended. An elapsed period of more than 30 days is permitted for SNF admissions where the patient's condition makes it medically inappropriate to begin an active course of treatment in a SNF immediately after hospital discharge, and it is medically predictable at the time of the hospital discharge that he or she will require covered care within a pre-determinable time period. The fact that a patient enters a SNF immediately upon discharge from a hospital, for either covered or non-covered care, does not necessarily negate coverage at a later date, assuming the subsequent covered care was medically predictable.

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