The 14 day rule Medicare refers to the requirement that a patient must spend 3 consecutive days, not counting the day of admission, in a hospital or skilled nursing facility (SNF) in order to qualify for Medicare coverage of post-hospital skilled nursing facility care. This rule defines the minimum qualifying hospital stay that a beneficiary must meet before Medicare will cover SNF services.
What is the purpose of the 14 day rule?
The 14 day rule was implemented by Medicare to ensure that patients receiving SNF care truly require skilled nursing services that can only be provided in an SNF setting. It aims to prevent the inappropriate use of SNF services for patients who do not medically need skilled care. The 3 qualifying hospital days show that a patient has an acute medical need that requires skilled nursing interventions after hospital discharge.
How does the 14 day rule work?
Here is how the 14 day rule works:
- The patient must have a medically necessary hospital stay for at least 3 consecutive days, not counting the day of admission or discharge.
- The 3 qualifying days do not need to be the 3 days right before discharge, but they must be inpatient days.
- The day of discharge from the hospital is not counted toward the 3 days.
- Intervening days when a patient is on leave of absence or discharged from the hospital do not count towards the 3 days.
- The patient must be admitted to the SNF within 30 days of hospital discharge for the same condition treated during the hospital stay.
So in summary, a patient hospitalized for only 1 or 2 days would not qualify for SNF coverage under Medicare rules. The 3 qualifying inpatient days must occur sometime during the hospital stay, but not necessarily immediately preceding discharge.
Are there any exceptions to the 14 day rule?
There are a few exceptions that allow SNF coverage without a 3 day qualifying hospital stay. These include:
- If a patient was previously living in a SNF receiving Medicare-covered care, they do not need a new 3 day stay to resume SNF care.
- Patients requiring skilled rehabilitation services for a condition treated during a previous qualifying hospital stay within the past 30 days may return to the SNF without another 3 day stay.
- If a patient has begun receiving Medicare-covered SNF care and then requires hospitalization again, they do not need another 3 day stay to resume SNF care.
What happens if the 14 day rule is not met?
If a patient did not have the required 3 day medically necessary hospital stay, Medicare will not cover any portion of the subsequent SNF care. In this case:
- The patient is responsible for all costs of SNF care.
- Medicare will not pay the SNF facility for services provided.
- The patient cannot appeal for Medicare coverage of the SNF stay.
It is important for hospitals and SNFs to coordinate carefully to ensure the 14 day rule is met prior to SNF admission for Medicare beneficiaries. Patients should also understand the requirements to avoid unexpected denial of SNF coverage.
When does the 14 day period start and end?
The 14 day period starts on the first day of the medically necessary 3 day qualifying hospital stay. It ends 14 days after discharge from the hospital. Counting the day of discharge as day 1, the SNF benefit can start on day 1 and continue through day 14 after hospital discharge.
For example:
- Hospital qualifying stay: Day 1-3
- Day of discharge: Day 4 (not counted as qualifying day)
- SNF benefit period: Day 4-18
The patient must be admitted to the SNF within 30 days of hospital discharge, and the benefit covers up to 14 days of SNF care from the day of discharge.
Does the 14 day rule apply to swing bed services?
Yes, the 14 day rule does apply to Medicare coverage of swing bed services in rural hospitals. Swing bed services refer to situations where a rural hospital provides SNF-level care in its own beds. For Medicare to cover swing bed services, the beneficiary must have a prior 3 day qualifying hospital stay just as required under the 14 day rule for SNF admissions.
How are the 14 days calculated?
The 14 days of SNF benefits are calculated as follows:
- The day of admission to the SNF counts as day 1, even if admission occurred in the evening.
- The day of discharge from the SNF does not count and is not billable.
- If a patient exhausts the 14 days but remains in the SNF, each additional non-covered day is billed as a room and board charge to the patient.
Weekends, holidays, and leave of absence days all count toward the 14 days. Interrupted stays across multiple SNF admissions can combine to total 14 days of coverage as long as within 30 days of hospital discharge.
What SNF services are covered under the 14 days?
Medicare Part A covers the following SNF services for up to 14 days when criteria are met:
- Semiprivate room and meals
- Skilled nursing care
- Physical therapy, occupational therapy, speech therapy
- Medications administered as part of care
- Necessary medical supplies and appliances
Custodial care is not covered. Services will only be covered if the patient continues to require skilled care and makes progress toward rehabilitation goals.
Is prior authorization required for SNF admissions?
As of October 2019, Medicare requires SNFs to obtain prior authorization through the Medicare Administrative Contractor (MAC) before admitting patients for post-hospital extended care services. This applies to both original Medicare and Medicare Advantage plans. Prior authorization helps ensure compliance with eligibility and coverage rules like the 14 day requirement.
Can a patient qualify for more days beyond 14?
In some cases, a patient who continues to require skilled nursing care beyond the 14 days can qualify for an additional period of coverage. To request more days, the SNF must submit a prior authorization request to Medicare with documentation showing that skilled care is still medically necessary. Medicare will review and make a coverage determination approving or denying additional days beyond 14.
Conclusion
The 14 day rule remains an important prerequisite for Medicare SNF coverage after a hospital stay. Understanding the details of this rule can help hospitals and SNFs coordinate to ensure a smooth transition and avoid denial of payment. While designed to prevent unnecessary SNF stays, exceptions do allow for some flexibility when medically warranted. With proper documentation and prior authorization, coverage may also extend past 14 days when the need for skilled care persists.
Here is a summary of the key points about Medicare’s 14 day rule for SNF care:
- Requires 3 inpatient qualifying days in hospital for SNF coverage
- Inpatient days may be non-consecutive during hospital stay
- Day of discharge is not counted toward 3 days
- Limited exceptions exist like prior SNF stay
- SNF care must begin within 30 days of hospital discharge
- Covers up to 14 days starting day of hospital discharge
- Requires prior authorization from Medicare
- Extra days may be approved if skilled care remains necessary