Three-Day Qualifying Hospital Stay Required for Medicare-Covered SNF Stay

Medicare coverage of inpatient SNF services requires a qualifying, medically necessary inpatient hospital stay of at least three consecutive calendar days within 30 calendar days prior to admission to a SNF. This is often referred to as the QHS.

Counting Days

Time spent in observation or in the emergency department prior to the inpatient admission does not count toward the QHS, as these are considered outpatient services. The beneficiary must be formally admitted to the hospital to count toward a QHS.
When counting days, the day of admission, but not the day of discharge, is counted as an inpatient hospital day.
The hospital discharge must occur on or after the first day of the month the beneficiary became entitled to Medicare.
A QHS can consist of consecutive inpatient stays in one or more hospitals which total three or more days (not including the date of discharge).
The hospital(s) must be either a Medicare-participating hospital or an institution, including a foreign hospital, that meets at least the conditions of participation for an emergency services hospital. Inpatient stays in Religious Nonmedical Health Care Institutions do not meet the QHS requirement.
A QHS does not need to be in a hospital that a SNF has a transfer agreement with.

Medical Necessity

To be eligible for coverage under the SNF benefit, the beneficiary must be admitted to the SNF for one of the following:
- Continued treatment of either a condition for which the beneficiary was receiving inpatient hospital services
- A condition which arose while in the SNF for treatment of a condition for which the beneficiary was previously hospitalized
The QHS must have been medically necessary. If a beneficiary’s care during a hospital stay becomes less intensive during the latter part of the stay, it may still be considered as a QHS as long as some portion of the stay included at least three consecutive days of medically necessary inpatient hospital services.
When a beneficiary in a hospital inpatient stay drops from an acute- to SNF-level of care but a SNF bed is not available, the stay may still be considered as a QHS. In this situation, the physician must certify that the beneficiary’s continued inpatient stay in the hospital is medically necessary under the circumstances.
If the entire inpatient hospital stay is deemed noncovered (e.g., not reasonable and necessary or considered custodial care), these hospital days do not count toward the QHS. If only part of the inpatient stay is covered, only the covered portion of the hospital stay can be used to satisfy the QHS requirement.
When a beneficiary in a current hospice election period receives inpatient hospital care for three days or more and chooses to revoke their hospice election, this stay could be considered a QHS even though the care would not be equivalent to a hospital level of care.
- A beneficiary in a covered hospice election period may be eligible to receive SNF care for a condition that is not related to the terminal condition. Both the QHS and the SNF claim(s) must be billed with condition code 07 to indicate this situation.

Beneficiary Notice

When the QHS requirement has not been met, SNFs are not required to issue a SNF ABN (CMS-10055) to the beneficiary. Voluntary use of the SNF ABN in this situation is encouraged to ensure that the beneficiary understands they will be liable for the SNF inpatient stay if they choose to be admitted.

Billing Reminders

When the beneficiary does not meet the technical requirements for SNF coverage, they may choose to still be admitted to the SNF.
If the beneficiary is not at a Medicare skilled level of care upon admission, the SNF is not required to bill Medicare. However, the SNF must submit a demand bill upon the request of a beneficiary.
When the beneficiary is at a Medicare skilled level of care upon admission, the SNF is required to submit covered claims to Medicare to extend the beneficiary’s existing benefit period in the CWF. These claims are billed as covered but without occurrence span code 70 (prior qualifying hospital stay) and will reject for no QHS.
In a situation where the beneficiary had a QHS, was admitted to a SNF at a skilled level of care but then dropped to a non-skilled level of care for more than 30 days, the original QHS would no longer apply if the beneficiary once again required a skilled level of care. When the duration of the non-skilled care was more than 30 days but fewer than 60 days, the beneficiary would not be eligible for a new benefit period. If the beneficiary had a new QHS and met all the other coverage requirements, they would be able to use any remaining days in their benefit period.

Beneficiaries in a Medicare Advantage (MA) plan

An MA plan may waive the QHS requirement for their enrollees. When a beneficiary has or had an MA plan, use the chart below for Medicare coverage and billing guidelines based on the situation:

If Beneficiary...	Then...
Is a current MA plan enrollee	Submit information-only claims to Medicare so the CWF can track the beneficiary’s benefit period. Report: Appropriate HIPPS code based on assessment or HIPPS ZZZZZ if no assessment happened Room and board charges Condition code 04
Disenrolls from MA plan and returns to Medicare while a SNF inpatient	Medicare waives the QHS requirement, and the beneficiary is eligible for the number of days remaining in the 100-day benefit period for that stay, minus the days Medicare would have covered while the patient was enrolled in an MA plan. Report condition code 58 on claim sent to Medicare.
Disenrolls from MA plan after SNF discharge, returns to Medicare and SNF readmits beneficiary under the 30-day rule	Beneficiary must meet all Medicare requirements, including the QHS. SNFs may charge coinsurance as applicable. Report condition code 58 on claim sent to Medicare.
Disenrolls from MA plan before SNF admission	Beneficiary must meet all Medicare requirements, including the QHS. SNFs may charge coinsurance as applicable. Report condition code 58 on claim sent to Medicare.