As The Covid Health Emergency Ends, Medicare Will Stop Paying For Many Skilled Nursing Stays

Because the Covid-19 public well being emergency ends, many older adults who want a post-hospital keep in a talented nursing facility (SNF) might be in for an disagreeable shock: Conventional Medicare could not pay.

The change, one among dozens that affect older adults, restores guidelines from earlier than the pandemic. However they’re sophisticated and can shock many sufferers and their households, depart some with out care, and drive others to residence well being care, which Medicare does pay for.

The essential pre-Covid rule stated that conventional Medicare would pay for a SNF keep provided that a affected person was first admitted to a hospital for not less than three consecutive days. Others must pay out of their very own pocket. Medicare waived that rule in the course of the pandemic however now it’s again.

Remark Standing

Right here is the issue: Many sufferers keep within the hospital underneath what is named observation status. They’re in a hospital mattress, cared for by hospital docs and nurses, and eat hospital meals. However they don’t seem to be admitted as inpatients. Thus, even sufferers who stay in an commentary unit for greater than three days received’t qualify for Medicare SNF care.

As well as, commentary stays are paid by Medicare Half B (the one you pay premiums for), not Half A hospital insurance coverage (the one partially funded with payroll taxes). Medicare sufferers who’ve solely Half A should foot the invoice for that commentary keep until they’ve another insurance coverage.

And it will get extra complicated. Medicare encourages hospitals to maintain commentary sufferers for the shortest time potential, often lower than 48 hours. That is, weirdly, referred to as the “two-midnight rule.” However generally sufferers keep longer. Others could break up their time between commentary and inpatient standing. Regardless of, if they don’t seem to be admitted as a hospital inpatient for not less than consecutive three days, Medicare will not pay for SNF care.

Think about, for instance, an 86-year-old widow goes the emergency room with shortness of breath. The docs wish to monitor her within the hospital for a number of days. She is going to virtually actually be handled as an commentary affected person.

An after an extended wait within the emergency room and two days in a hospital mattress, she possible might be weak and debilitated. And she or he could don’t have any member of the family to take care of her at residence. But when she is discharged to a SNF to get her power up, it is going to be on her dime. Medicare received’t pay.

One other instance: That 86-year-old widow has surgical procedure within the hospital to restore a fractured hip. Normally, Medicare treats that surgical procedure as an outpatient process, though it was executed in a hospital working room. Until she is admitted as an inpatient for not less than three days, Medicare won’t pay for her SNF keep even when she wants intensive rehab.

Hospitals are supposed to provide sufferers a written explanation of all this. However few learn it and ever fewer perceive it. In order that SNF invoice is a shock.

Affected person Backlash

When this rule was in impact earlier than Covid, sufferers typically had been livid at hospitals. “Why don’t they only admit me as an inpatient?” they’d ask.

Fact is, the specific objective of this rule is to scale back Medicare’s hospital and SNF prices. It encourages outpatient orthopedic surgical procedures (like hips and knees) as a result of they price much less for related outcomes.

Medicare additionally pays the hospital much less for an commentary affected person than for an inpatient. And if a hospital is later discovered to have admitted a affected person who ought to have been in commentary, the hospital should refund to Medicare its complete cost for that case.

There are some exceptions to the three-day rule. Members of Medicare Benefit plans, which now cowl greater than half of all Medicare recipients, can use SNFs for post-acute care at no further price—so long as they use an in-network facility. And Medicare additionally pays if SNF stays are a part of treatment by primary care practices known as Accountable Care Organizations.

Advocating For Change

Hospitals, nursing homes, and patient advocates have lobbied Congress for years to vary the three-day rule. They are saying well being care has modified a lot that the requirement is out of date. Not solely is widespread commentary standing a comparatively new apply however common hospital stays are a lot shorter now.

It isn’t clear what would occur if the rule is repealed. When it was briefly dropped in 1989, Medicare SNF admissions increased by 16 percent. We don’t but perceive the affect of the pandemic-related waiver.

What’s going to occur now? Many conventional Medicare sufferers will get their post-hospital care at residence, which they typically choose and the place Medicare typically does pay. However residence well being received’t work for everybody. The perfect step ahead is for Medicare to discover a approach to pay for post-acute care in probably the most applicable setting, wherever which may be.