What Case Managers Need to Know About the 3-Day Rule for SNF Stays

The end of the public health emergency (PHE) brings new challenges regarding the old Three-Day rule.

The three-day stay for Medicare patients is the requirement that based on the time of the order for inpatient, the patient must pass three midnights of continued inpatient hospital care to qualify for skilled nursing placement. 

The reminder of this rule is important for many case managers as we have had a break for the last two years from counting midnights.  This will be one more thing that case managers will need to make sure they are tracking when it comes time to transfer qualifying Medicare patients to skilled nursing facilities.  The two-day rule for inpatient stay specifically applies to traditional Medicare patients, patients that have a Medicare Advantage (MA) plan have specifications in their contract and provider manual that may allow the transfer of patients to skilled placement regardless of the three-day rule or even the requirement of inpatient admission. 

Case managers will want to check their hospital contracts and verify during the skilled nursing authorization period if the contracted payer will once again make this a requirement.  I would expect the hospital case management team to be up to date on this expectation as one cannot rely on the skilled nursing facility (SNF) to know the exact date and time of the inpatient order.  However, similar to before the PHE, it was a common occurrence for case managers to submit a copy of the inpatient order when sending clinicals to the post-acute facility to verify the inpatient admission date and time.

There are some additional specifications to the rule that is important to remember.  The qualification of the three-day stay surrounds two calendar periods— a 30-day period and a 60-day period of benefits. 

The 30-day period states that if a patient has a break in skilled care that lasts more than 30 days, they will need a new three-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be in the same condition that they were treated for during the previous stay.

For patients that do not have a 30-day break in skilled care, then the three-day stay rule does not apply.  For example, a patient was inpatient on the index admission for four inpatient hospital days, the patient was recommended for SNF, but elected to go home with home health instead.  The patient went home for two days and realized this was a terrible idea and returned to the hospital.  The patient was readmitted as outpatient with observation services and recommended again for SNF placement.  The patient would still be eligible for SNF placement because they completed a qualifying inpatient hospitalization during their index admission, and it was within the 30-day period.

Patients that go to SNF must also have a 60-day break from utilization in order for their SNF benefits to renew. This means that a patient that was in the hospital and then spent 24 days in the SNF, then returned the next week to the hospital and then needed to discharge to skilled again, would not renew their benefits. They would go straight into the continuation of the previous benefit period which would be the patient’s coinsurance days 21-100, this could be up to $200/day unless the patient has a secondary to help cover the cost.

In summary, case managers will need to remember the following-

1. With the end of the PHE, the three-day rule for SNF placement as returned for traditional Medicare patients.  Meaning patients will need a three midnight stay from the time of the inpatient order in the hospital to qualify for SNF placement if medically necessary. 
2. Patients who have had a qualifying hospitalization within a 30-day period and return to the hospital for either emergency or observation services can still transfer to SNF if medically appropriate without having another three-day inpatient stay.
3. This rule may not apply to MA, Medicaid, or commercial plans, this will be up to the payer contract and provider manual.
4. Patients with high utilization of SNF placement must be out of acute care for 60-days for their benefits to restart otherwise their SNF stay will resume at the previous benefit day count of coverage.

Programming note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health (SDoH) every Tuesday, 10 Eastern, on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.