Reminder: CMS' Two-Midnight Rule doesn't apply to Medicare Advantage members

The Centers for Medicare and Medicaid Services’ (CMS) Two-Midnight Rule doesn’t apply to Priority Health members because our members have a Medicare Advantage (MA) plan.

Why doesn't this rule apply to our members?

Our members are part of an MA plan and, therefore, not subject to Medicare Part A rules.1 Instead, CMS defers to our provider contracts and doesn’t require us to include the Two-Midnight Rule. This allows us, in collaboration with contracted providers, to set our own criteria, as long as our members receive the same benefits as outlined under Medicare Part A.

What is the Two-Midnight Rule?

On Oct. 1, 2013, CMS began using the Two-Midnight Rule. This rule established Medicare payment policy regarding whether an inpatient admission is reasonable and necessary for purposes of payment under Medicare Part A.

In general, the original Two-Midnight rule stated that:

• Inpatient admissions would generally be payable under Part A if the admitting practitioner expected the patient to require a hospital stay that crossed two midnights and the medical record supported that reasonable expectation.
• Medicare Part A payment was generally not appropriate for hospital stays expected to last less than two midnights.

 

¹CMS Account Management Standard Operating Procedure 5.3.2