Qualifying Hospital Stay

To understand a qualifying hospital stay in the context of placement in a rehabilitation facility, it's crucial to differentiate between two main types of post-acute care facilities covered by Medicare Part A:

  1. Skilled Nursing Facilities (SNFs): These facilities provide skilled nursing care and/or skilled rehabilitation services (like physical, occupational, or speech therapy) on a daily basis. They are often part of nursing homes or hospitals.

  2. Inpatient Rehabilitation Facilities (IRFs), also known as rehabilitation hospitals: These facilities offer more intensive rehabilitation, typically requiring at least three hours of therapy per day, along with 24-hour access to a doctor and a rehabilitation-trained nurse.

The concept of a "qualifying hospital stay" primarily applies to Skilled Nursing Facility (SNF) placement under Medicare Part A (see below).

Elderly man in a hospital room using parallel bars with a healthcare worker assisting.

Qualifying Hospital Stay for Skilled Nursing Facility (SNF) Coverage

For Medicare Part A to cover a stay in a Skilled Nursing Facility (SNF), a beneficiary generally needs to have a "qualifying hospital stay." This means:

  • 3-Day Inpatient Stay: The individual must have been formally admitted to a hospital as an inpatient for at least three consecutive days.

    • Counting Days: The day you are admitted as an inpatient counts, but the day you are discharged does not.

    • Observation Status Does Not Count: Time spent in the emergency room or under "observation status" in the hospital does NOT count towards the three-day inpatient requirement, even if you stay overnight. You must have a doctor's order formally admitting you as an inpatient.

  • Medical Necessity: The hospital stay must be medically necessary.

  • Timeliness of Admission to SNF: You must be admitted to the Medicare-certified SNF within a short time (generally 30 days) of being discharged from the qualifying hospital stay.

  • Need for Skilled Care: Your doctor must determine that you need daily skilled nursing care (e.g., wound care, IV medications) or skilled rehabilitation services (e.g., physical therapy, occupational therapy, speech-language pathology) that can only be provided by, or under the supervision of, skilled nursing or therapy staff in a SNF setting. This care must be for a condition treated during your qualifying hospital stay or a new condition that developed while receiving SNF care for the original condition.

Exceptions/Waivers:

  • Some Medicare Advantage Plans may waive the 3-day minimum inpatient hospital stay. It's crucial to check with the specific Medicare Advantage Plan.

  • Certain Medicare initiatives, such as some Accountable Care Organizations (ACOs), may have waivers for the 3-day rule to allow for more flexible care transitions.

Impact on Coverage: If you meet the qualifying hospital stay and other criteria, Medicare Part A will cover up to 100 days of SNF care per "benefit period."

  • Days 1-20: You typically pay nothing.

  • Days 21-100: You pay a daily coinsurance (which changes annually).

  • Day 101 and beyond: You are responsible for all costs.

A "benefit period" starts the day you're admitted as an inpatient to a hospital or SNF and ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you return to a SNF within 30 days of leaving, a new qualifying stay is usually not required. However, if your break in skilled care lasts more than 30 days, you'll generally need a new 3-day qualifying hospital stay to qualify for further SNF benefits.

Inpatient Rehabilitation Facilities (IRFs)

For Inpatient Rehabilitation Facilities (IRFs), while a prior hospital stay is common, the 3-day inpatient rule does NOT directly apply in the same strict way as for SNFs. Instead, to qualify for Medicare Part A coverage in an IRF, the primary criteria are:

  • Intensive Rehabilitation: Your medical condition must require intensive rehabilitation (generally at least 3 hours of therapy per day, 5-7 days a week).

  • Medical Supervision: You need continued medical supervision by a doctor.

  • Coordinated Care: You need coordinated care from a team of health professionals (doctors, therapists, nurses).

  • Improvement Potential: Your doctor must expect your condition to improve significantly, allowing you to function more independently as a result of the stay.

While many IRF admissions follow an acute hospital stay, the length of that initial hospital stay is not the determining factor for IRF coverage in the way it is for SNFs. The focus for IRFs is on the intensity and expected outcomes of the rehabilitation itself.