A reminder about the Medicare Part A SNF 30 Day Transfer Rule. The Medicare Part A Skilled Nursing Facility (SNF) 30-Day Transfer Rule is a policy that affects how Medicare pays for post-hospital extended care services in a skilled nursing facility.
Under this rule, if a Medicare beneficiary is admitted to a hospital and then transferred to a SNF for skilled nursing care within 30 days of discharge from the acute care, the beneficiary may access SNF Medicare Part A Days without another 3 Day qualifying stay. This rule has nothing to do with the COVID-19 Waivers.
Example 1: An individual is admitted to the hospital for a fractured hip and undergoes surgery for an ORIF. After 5 days in the hospital, the individual is discharged to home. The Pneumonia is a condition that resulted from limited, but increasing mobility, secondary to the fractured hip. Because the individual was admitted to the SNF within 30 days from the hospital discharge, he/she can access Medicare Part A Benefits without a 3-night qualifying hospital stay. If the individual (in this example) was admitted to the SNF on day 31, he/she cannot access Medicare Part A benefits until he/she has a 3-night qualifying hospital stay.
Example 2: An individual is admitted to the SNF for a fractured hip post surgery. The Medicare Team skills the individual for 58 days. Every week, for 4 weeks, the Medicare Team reviews the health status of this individual. On week 3, the Nurse Manager reports that the individual has a fever (2.4-degree Fahrenheit change from baseline) and an X-Ray revealed Pneumonia. The Medicare Team immediately resumes Medicare Part A Coverage for this individual, i.e., day 59, without a 3-night qualifying stay. Again, the Pneumonia is a condition that resulted from limited, but increasing mobility, secondary to the fractured hip. If the individual (in this example) acquires Pneumonia on day 31, he/she cannot access Medicare Part A benefits until he/she has a 3-night qualifying hospital stay.
(Example 2 spurs the question: At the weekly Medicare Meeting, does the Medicare Team review Medicare Part A Patients who remain at the facility, after the Medicare Team discontinues skilled services?)
The Medicare 30-Day window is in place to allow a Beneficiary access to remaining skilled days after a period at a non-skilled level without requiring another 3-Day qualifying hospital stay. To re-access benefits, the new condition must be related to a condition or problem the resident received care for during the 3-Day hospital stay or during the SNF stay following the 3-Day hospital stay.
This subject matter is further explained in Chapter 8, Section 20.1, of the Medicare Benefit Policy Manual on page 8 of 58 pages. In addition, the below narratives are excerpts from that same page.
Chapter 8: Page 8, 20 – Prior Hospitalization and Transfer Requirements (Rev. 1, 10-01-03) A3-3131, SNF-212
“In order to qualify for post-hospital extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least three consecutive
calendar days. In addition, effective December 5, 1980, the individual must have been transferred to a participating SNF within 30 days after discharge from the hospital, unless
the exception in §20.2 applies.”
20.1 – Three-Day Prior Hospitalization (Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)
“In accordance with section 226(c)(1)(B) of the Social Security Act and the implementing regulations at 42 CFR 409.30(a)(2), the hospital discharge must have occurred on or after
the first day of the month in which the individual attained age 65 or, effective July 1, 1973, became entitled to health insurance benefits under the disability or chronic renal
disease provisions of the law. The 3 consecutive calendar day stay requirement can be met by stays totaling 3 consecutive days in one or more hospitals.”
“In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day.”
“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 3-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. See 31 Fed. Reg. 10116, 10118-19 (July 27, 1966).”
“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 (including services of an emergency hospital) 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.”
As always, please feel free to call or text me at 617.595.6032.