Short Stay Policy Updates

In October, we notified you of changes to the Short Stay policy in response to CMS 2024 rules updates. Medicare Advantage plans are now required to adhere to the CMS 2 Midnight Rule when determining hospital inpatient admission level of care.

In response to the CMS 2024 rules updates Buckeye Health Plan has revised the Short Stay Policy with the following exclusions:

1. It is the policy of Medicare health plans affiliated with Centene Corporation^® that inpatient hospital stays (vs. observation) spanning less than two midnights are medically necessary when meeting any of the following criteria:
   • Admission is for a procedure on the current calendar year CMS Inpatient Only List (2023 addendum E, 2024 addendum E);
   • The admitting physician expects the patient to require hospital care that crosses two-midnights based on consideration of complex medical factors documented in the medical record. Such requests will be reviewed on a case-by-case basis by a medical director, considering factors such as member/enrollee history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event occurring during the time period for which hospitalization is considered;
   • The admitting physician does not expect the patient to require care that crosses two midnights, but determines, based on complex medical factors documented in the medical record that inpatient care is nonetheless necessary. Such requests will be reviewed on a case-by-case basis by a medical director, considering factors such as member/enrollee history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event occurring during the time period for which hospitalization is considered;1
   • Admission to an intermediate or intensive care unit level of care is considered medically necessary per a nationally-recognized clinical decision support tool;
   • Admission to acute hospital care at home;
   • Unexpected death during the admission;
   • Departure against medical advice from a medically necessary (per a nationally-recognized clinical decision support tool) inpatient stay;
   • Transferred from another facility, with a medically necessary (per a nationally-recognized clinical decision support tool) total length of stay greater than two days;
   • Election of hospice care in lieu of continued treatment in hospital.
2. It is the policy of Medicare health plans affiliated with Centene Corporation that inpatient hospital stays on day three and beyond are medically necessary when supported by nationally-recognized clinical decision support tools.

The final rule can be found at the American Hospital Association website.