Understanding the Medicare "Extended Care Benefit" a.k.a. the 3-midnight rule

The purpose of this article is to discuss the overall features of the "Extended Care Benefit," also known as the 3-midnight rule for post-acute skilled nursing facilities (SNF) coverage. The goal is to support case managers in the effort to gain a better understanding of how the benefit applies to the Medicare beneficiaries with whom they are working.

(1) Give a brief history of the purpose of the "extended care benefit," (2) describe the circumstances under which a patient may be eligible for coverage of skilled nursing or rehabilitation services following a hospitalization, and (3) apply new knowledge to practice by incorporating case management tips into practice.

The primary setting for case managers who need to know this information is in acute care and in postacute care facilities that admit patients for extended care services.

The eligibility of Medicare beneficiaries for this benefit may be broader than is commonly known by case managers.

1. Case managers should not "assume" that the patient does not meet criteria for this benefit. For example: Even if the patient is not ready for rehabilitation services at the time of discharge, a case manager can advocate for deferred admission when the patient is ready. 2. Case managers should include in the patient's admission assessment, the history of previous hospitalizations, particularly in the past 30 days. The patient may have met the 3-midnight requirement prior to admission. 3. Hospital-based case managers must work closely with intake staff, case managers, or liaison staff from the SNF level of care to do a comprehensive assessment of the patient's continuing care needs. 4. Delivering the message to Medicare beneficiaries and their families that the patient does not meet criteria for "extended care services" is a very difficult task and should be done in collaboration with other team members, particularly social workers. 5. With 43% of all admissions of patients being in the "short-stay" category, early intervention is critical to determine the possibility of the patient's postacute needs. It is the short-stay patient who does not meet medical eligibility for 3 days who needs more attention early in the stay. 6. Keeping a patient in the hospital, who does not meet medical necessity standards, even for 1 day with the purpose of meeting the 3-day rule may be considered to be "fraudulent," and is a serious matter. Acute care setting is intended to provide acute care services and not to be used to help "needy" individuals meet criteria for extended care benefits.