Medicare 3-Day Rule: Medicare can be confusing, especially when it comes to hospital stays and skilled nursing care. There are lots of rules and different parts, like Part A, Part B, Part C, and Part D, some of which are optional.
But for almost 69 million Americans who use Medicare, knowing these rules is really important because it can affect how much you pay out of your own pocket. One rule that many people don’t know about is called the “3-day rule.” This rule can decide if Medicare pays for rehab in a skilled nursing facility or if you have to pay the full bill yourself.
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What is 3-day rule in Medicaid?
The 3-day rule means that you must stay in the hospital as a patient for at least three nights in a row before Medicare Part A will cover care in a skilled nursing facility (SNF). Only the nights you spend in the hospital count, not the day you leave. Time spent in the emergency room or in observation before being admitted doesn’t count. For example, if you get admitted late on Friday night, that first night counts as day one.
You need to stay until Sunday night to reach the three days for a Monday discharge. After leaving the hospital, you must go to a Medicare-approved SNF within 30 days, and the care must be for the same reason you were in the hospital. The facility has to give daily skilled care or rehab that can only be done there. If these conditions aren’t met, Medicare probably won’t pay.
How the 3-Day Rule Affects Your Costs
This rule has a big effect on your money. Depending on the length of your stay in the SNF, you may also be required to pay the following:
- Days 1 to 20: You pay $0 each day after you pay the $1,676 deductible.
- Days 21 to 100: You pay $209.50 each day.
- Days 101 and beyond: You pay all costs. You must also pay all additional charges not covered by Medicare (like phone and laundry fees).
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Exemptions and Considerations for the Medicare 3-Day Rule
- Medicare Advantage Waivers: If you have a Medicare Advantage plan, it can sometimes ignore the three-day hospital requirement. Many plans do this to make it easier for patients to get skilled care.
- Accountable Care Organizations (ACOs): If your doctor is part of an ACO or another approved Medicare program, you might not need to stay three days in the hospital.
- Value-Based Payment Models: Hospitals or organizations that take part in risk-sharing programs can often waive the three-day rule for patients.
- Re-Admission Flexibility: If you go back to a skilled nursing facility within 30 days, you don’t need another hospital stay. This also works if you paused your skilled care and start it again within 30 days.
- Appeal Rights: If the hospital changes your status from inpatient to observation, you can appeal. Winning the appeal might make you qualify for skilled nursing coverage retroactively.
