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 might not pay.

The change, one amongst dozens that have an effect on older adults, restores guidelines from earlier than the pandemic. However they’re sophisticated and can shock many sufferers and their households, go away some with out care, and drive others to dwelling well being care, which Medicare does pay for.

The fundamental pre-Covid rule mentioned that conventional Medicare would pay for a SNF keep provided that a affected person was first admitted to a hospital for at the least 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.

Commentary Standing

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

As well as, remark 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 must foot the invoice for that remark keep except they’ve another insurance coverage.

And it will get extra complicated. Medicare encourages hospitals to maintain remark sufferers for the shortest time attainable, normally lower than 48 hours. That is, weirdly, referred to as the “two-midnight rule.” However generally sufferers keep longer. Others might cut up their time between remark and inpatient standing. Regardless of, if they aren’t admitted as a hospital inpatient for at the least 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 remark affected person.

An after a protracted wait within the emergency room and two days in a hospital mattress, she doubtless might be weak and debilitated. And he or she might haven’t any member of the family to take care of her at dwelling. But when she is discharged to a SNF to get her energy up, will probably 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. Generally, Medicare treats that surgical procedure as an outpatient process, although it was achieved in a hospital working room. Until she is admitted as an inpatient for at the least three days, Medicare is not going to pay for her SNF keep even when she wants intensive rehab.

Hospitals are supposed to provide sufferers a written rationalization 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 usually have been livid at hospitals. “Why don’t they simply admit me as an inpatient?” they’d ask.

Reality is, the express goal 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 comparable outcomes.

Medicare additionally pays the hospital much less for an remark 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 remark, the hospital should refund to Medicare its total 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 additional price—so long as they use an in-network facility. And Medicare additionally pays if SNF stays are a part of remedy by main care practices often known as Accountable Care Organizations.

Advocating For Change

Hospitals, nursing houses, and affected person advocates have lobbied Congress for years to alter 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 remark standing a comparatively new apply however common hospital stays are a lot shorter now.

It’s not clear what would occur if the rule is repealed. When it was quickly dropped in 1989, Medicare SNF admissions elevated by 16 p.c. We don’t but perceive the influence of the pandemic-related waiver.

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