Understanding Medicare’s “3-Midnight Rule” for Skilled Nursing Facility Coverage

by | Oct 21, 2025 | General, Rules & Enrollment

If you ever need short-term rehabilitation or skilled nursing care after a hospital stay, one Medicare rule could make all the difference in whether your care is covered — the 3-midnight rule. This often-overlooked guideline determines when Medicare Part A will pay for a Skilled Nursing Facility (SNF) stay, and misunderstanding it can lead to costly surprises.

As a trusted, independent Medicare brokerage, Emerald Medicare helps clients across the country navigate these details with confidence. Here’s what you need to know about how the 3-midnight rule works — and how to protect yourself from unexpected expenses.

What is the 3-Midnight rule?

To qualify for Medicare coverage of a skilled nursing facility stay, you must first have a 3-day inpatient hospital stay. This means:

  • You must be formally admitted as an inpatient, not under observation or emergency status.
  • The stay must include three consecutive midnights in the hospital.
  • The day of admission counts, but the day of discharge does not.

For example, if you’re admitted on a Monday, stay through midnight on Wednesday, and are discharged on Thursday, your stay meets the 3-midnight requirement.

This rule exists because Medicare only covers skilled nursing facility care when it follows a qualifying inpatient hospital stay. Without it, you may be responsible for the full cost of care — which can add up quickly.

Why Observation Status Matters

A common point of confusion is the difference between being “admitted” and being “under observation.”
Even if you stay overnight or longer, observation status is considered outpatient care. Unfortunately, that time does not count toward the 3-day inpatient requirement.

Before you leave the hospital, ask a simple but crucial question:

“Was I officially admitted as an inpatient?”

Hospital staff can verify your status so you know whether your SNF stay will qualify for Medicare coverage.

    Are There Exceptions to the Rule?

    Yes — and they’re becoming more common. Some programs waive the 3-day requirement altogether:

    • Medicare Advantage Plans: Many Medicare Advantage (Part C) plans waive the 3-midnight rule, allowing coverage for SNF care without a prior hospital stay. Check with your specific plan to confirm.
    • Other programs: Medicaid or Veterans’ benefits may help cover costs if you don’t meet the Medicare rule.

    What You Should Do Before Leaving the Hospital:

    1. Confirm your admission status. Make sure your stay was inpatient, not observation.
    2. Talk to your care team. Ask if your hospital participates in any ACO or waiver program.
    3. Contact your Medicare plan. Whether you have Original Medicare or a Medicare Advantage plan, confirm coverage and potential exceptions before discharge.

    Plan Ahead with Emerald Medicare
    Understanding Medicare’s 3-midnight rule can protect you from major out-of-pocket expenses and ensure your care transitions are covered. At Emerald Medicare, our licensed Medicare specialists are here to explain these rules in plain language — and help you plan ahead for the unexpected.

    If you have questions about skilled nursing coverage or your Medicare plan, we’re here to help.

    Reach out to Emerald Medicare Today!

    Contact Us
    📞 (888) 683-6372 or (845) 358-1220
    📧 office@emeraldmedicare.com

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    How Do I Apply for Medicare?

    by | Oct 9, 2025 | Medicare Advantage, Medicare Supplement, Original Medicare, Prescription Drug Coverage, Rules & Enrollment

    Understanding the Medicare Application Process

    Enrolling in Medicare is a major milestone in your healthcare journey, but it doesn’t have to be confusing. Whether you’re approaching age 65 or qualifying earlier due to disability, knowing when and how to apply ensures you avoid gaps in coverage or penalties. Here’s a step-by-step guide to applying for Medicare with confidence.

    Eligibility: Who Can Apply for Medicare

    You are generally eligible for Medicare if:

    • You’re 65 or older, and either a U.S. citizen or a permanent resident who’s lived in the U.S. for at least five years.

    • You’re under 65, but have received Social Security Disability Insurance (SSDI) for 24 months.

    • You have End-Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s Disease).

    If you’re already receiving Social Security benefits, you’ll be enrolled automatically in Medicare Parts A and B. Otherwise, you’ll need to apply manually through the Social Security Administration.

    How to Apply for Medicare Parts A & B (Original Medicare)

    You can apply for Original Medicare in one of three ways:

    Online: Visit SSA.gov/Medicare

    By Phone: Call Social Security at 1-800-772-1213.

    In Person: Visit your local Social Security office.

    • Part A (Hospital Insurance) covers inpatient hospital stays, skilled nursing, and hospice care.

    • Part B (Medical Insurance) covers doctor visits, preventive care, outpatient services, and durable medical equipment.

    If you’re still working and covered under employer insurance, you may choose to delay Part B to avoid paying unnecessary premiums—but it’s important to confirm this with your HR department or a licensed Medicare advisor before making that decision.

    Applying for Medicare Advantage (MAPD) Plans

    After enrolling in Parts A and B, you may decide to choose a Medicare Advantage Plan (Part C) instead of using Original Medicare as your primary insurance. These plans are offered by private insurance companies and often include additional benefits such as:

    • Bundled Prescription drug coverage

    • Additional dental, vision, and/or hearing benefits

    • Wellness programs and gym memberships

    Enrollment in a Medicare Advantage Plan is handled through the private insurer offering the plan, not through Medicare directly. The benefit of using a brokerage (like Emerald Medicare) to enroll in a MAPD plan is they will usually handle the enrollment & application process on your behalf, acting as the middleman between you and your insurance provider.

    Medigap (Medicare Supplement) Plans

    If you prefer to stay with Original Medicare, you can add a Medigap policy to help pay for costs that Parts A and B don’t cover—such as deductibles, coinsurance, and copayments.

    • You must have both Parts A and B to buy a Medigap plan.

    • Depending on your home state, you may or may not have to go through medical underwriting and wait for approval.

    Just like with a Medicare Advantage (MAPD) Plan, the best & easiest way to enroll in a Medigap plan is to reach out to your Medicare broker, who will advise you on the coverage options available in your zip code. Otherwise, you can reach out to the carriers directly to get prices and/or compare options, and even enroll directly with the carrier by reaching out to their customer service and/or new enrollment department. 

    Prescription Drug Plans (PDP – Part D)

    If you choose Original Medicare (if you do NOT choose an MAPD plan) you’ll likely also need a standalone Part D prescription drug plan.

    • These plans are also available through private insurance companies.

    • Enrollment is typically completed via Medicare.gov or directly through the plan’s website.

    • Make sure to review each plan’s formulary (drug list) to ensure your prescriptions are covered affordably.

    With Emerald Medicare, once you enroll in Original Medicare (Parts A/B), we walk you through all your coverage options and thoroughly explain how these options differ. We also handle your enrollment application(s) along with reviewing your list of Medications & Doctors to make sure there are no gaps in your coverage. 

    Get Guidance from the Medicare Experts

    Applying for Medicare doesn’t have to be stressful. At Emerald Medicare, our licensed experts can walk you through every step—from choosing Parts A and B to comparing Supplement, Advantage, and Part D options personalized to your needs.

    Start your Medicare journey confidently—contact Emerald Medicare today!

    (888) 683-6372 or (845) 358-1220

    info@emeraldmedicare.com

    Medicare HMOs vs. PPOs

    by | Oct 2, 2025 | Medicare Advantage

    Which Plan is Right for You?

    Choosing between a Medicare HMO (Health Maintenance Organization) and a Medicare PPO (Preferred Provider Organization) has always been about balancing cost with flexibility. But in today’s Medicare Advantage marketplace, the differences are becoming even more important. With Medicare plan changes in 2025 and shifting carrier strategies, it’s crucial to understand not only how these plans work but also how the landscape is evolving.

    As your trusted Medicare resource, Emerald Medicare is here to break down what these plans really mean for you and why reviewing your options carefully each year matters more than ever.

    The Basics: Medicare Provider Networks Explained

    A provider network is simply the list of doctors, hospitals, and other healthcare providers that contract with a Medicare Advantage (MAPD) plan. These providers agree to accept the plan’s payment terms, which helps the plan effectively manage their costs. That’s why staying in-network almost always results in lower out-of-pocket expenses.

    • Medicare HMO Plans: Require you to use in-network providers for coverage (except emergencies). You typically need to choose a primary care provider (PCP) who coordinates your care and provides referrals for specialists. Costs are often lower, and some Medicare Advantage HMOs even offer $0 premiums.
    • Medicare PPO Plans: Allow you to see both in-network and out-of-network providers. You don’t need referrals for specialists, but premiums and deductibles are generally higher. Out-of-network visits can mean significantly higher costs.

    Why Medicare PPOs Are Declining and HMOs Are Expanding

    In recent years, many carriers have started phasing out or scaling back Medicare Advantage PPO options. The reason is simple: PPOs are more expensive for insurance companies to maintain, and those costs are increasingly difficult to manage. By contrast, Medicare HMOs allow insurers to better control costs because care is funneled through networks and coordinated by primary care providers. This model has become more profitable and more sustainable for insurers — and as a result, HMOs are growing in availability.

    For beneficiaries, this means you’ll likely see more HMO Medicare Advantage plans in 2025, while PPOs may become less common or come with higher premiums to reflect the added flexibility.

    The Impact of the Inflation Reduction Act on Medicare Plans

    Starting in 2025, the Inflation Reduction Act introduces a $2,000 annual cap on out-of-pocket prescription drug costs. This change applies across Medicare Advantage plans, including both HMOs and PPOs. It’s a huge win for consumers, helping protect retirees from unpredictable, sky-high pharmacy bills.

    The law also allows Medicare to negotiate prices for certain high-cost drugs, which may help reduce overall costs in the system. This could benefit enrollees across both HMO and PPO plan types, though the exact impact will vary by medication and carrier.

    Hidden Medicare Plan Changes to Watch For

    Beyond these big themes, there are subtle changes that consumers often overlook. Carriers aren’t just restructuring plans; some are also reducing broker compensation or shifting benefits in ways that may not be obvious.

    For example, one Medicare Advantage plan in 2025 may advertise new perks like food cards or fitness memberships, while at the same time quietly reducing dental, vision, or over-the-counter allowances. These trade-offs don’t always get highlighted in marketing materials, which is why reviewing the Annual Notice of Change every fall is so important.

    Choosing the Right Medicare Advantage Plan for 2026 & Beyond

    When deciding between a Medicare HMO vs. PPO, ask yourself:

    • Do I want to keep my current doctors and specialists? Are they in-network on an HMO?
    • Am I comfortable coordinating my care through a primary care provider and getting referrals?
    • Would I rather pay a little more each month for the freedom to see providers outside the network?
    • How much do I rely on extra benefits like dental, vision, or over-the-counter allowances?

    There’s no one-size-fits-all answer. The right plan is the one that best aligns with your health needs, financial priorities, and comfort level with provider restrictions.

    Stay Ahead of Medicare Plan Changes With Emerald Medicare

    At Emerald Medicare, our role is to help you see past the fine print, understand how these changes affect you personally, and ensure you’re in the plan that delivers the best value. Don’t assume your plan will look the same just because it has in the past. Even plans with the same name can change dramatically from year to year.

    Click below to schedule an appointment with one of our Medicare Experts.

    Or, Contact Us
    📞 (888) 683-6372 or (845) 358-1220
    📧 office@emeraldmedicare.com

    Mark Brownstein, CSA® | Calendly

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    Why do Medicare benefits change each year?

    by | Sep 23, 2025 | Industry Shifts & Updates, Medicare Benefits

    If you’ve been on Medicare for more than a year, you’ve likely noticed that something always changes—whether it’s your plan premium, your drug coverage, or which doctors are in-network. Many people ask us: “Why doesn’t Medicare just stay the same?”

    The truth is, while Original Medicare (Parts A and B) stays relatively stable, Part D drug plans and Medicare Advantage plans are offered by private insurers—and they’re allowed (and expected) to make changes annually. Here’s why those changes happen—and more importantly, what you can do to stay ahead of them.

    Plans Adjustments Based on Federal Funding & Regulations

    Each year, the Centers for Medicare & Medicaid Services (CMS) announces changes to payment structures, coverage rules, and plan requirements. These updates are often tied to:

    • Inflation and rising healthcare costs
    • New laws like the Inflation Reduction Act
    • Changes in how much Medicare reimburses insurers

    📌 In 2026, for example, a major prescription drug cost overhaul is taking effect—impacting how plans structure their formularies and copays.

    Drug formularies are reviewed and modified each year

    If you have a Part D or Medicare Advantage plan with drug coverage, your insurer re-evaluates which medications they cover, how much they cost, and which pharmacies are preferred.

    That’s why your plan may cover your medication one year and drop it or raise the cost the next.

    💡 This is one of the top reasons we encourage clients to review their coverage every October—even if nothing else has changed.

    Premiums, Copays, and Deductibles change alongside market conditions

    Insurance companies adjust plan premiums, deductibles, and copay amounts based on:

    • Medical trends
    • Prescription drug pricing
    • Provider contracts
    • Member usage

    While these changes are often modest, some plans may increase costs significantly—or reduce benefits to keep premiums low.

    ⚠️ That “great plan” you had last year may no longer be the best value for you today.

    Plans can be discontinued or renamed

    Some plans are removed from the market entirely. Others are renamed or merged with similar options.

    In 2026, for example, several major carriers are terminating certain Advantage plans, impacting hundreds of thousands of beneficiaries nationwide.

    🏥 If your plan is discontinued, you’ll get a Special Enrollment Period—but waiting too long to act could lead to coverage gaps.

    ✅ What You Can Do: Review and Reassess Annually

    The Annual Enrollment Period (October 15 – December 7) exists for this exact reason: to give you the opportunity to switch plans, compare drug coverage, and adjust your Medicare strategy for the year ahead.

    At Emerald Medicare, we provide:

    • Coverage reviews every fall
    • Access to smart tools like RxCare for real-time drug plan savings
    • Help comparing Part D, Medigap, and Medicare Advantage options
    • Unbiased advice from licensed brokers (never pushy sales tactics)

    Be Proactive, Not Reactive

    The only constant in Medicare is change—but that’s not a bad thing. With a trusted partner on your side, these annual adjustments become opportunities to improve your coverage, reduce your costs, and feel more confident in your choices.

    Let us help you prepare for 2026 and beyond.

    Click below to schedule an appointment with one of our Medicare Experts.

    Or, Contact Us
    📞 (888) 683-6372 or (845) 358-1220
    📧 office@emeraldmedicare.com

    Mark Brownstein, CSA® | Calendly

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    Do I Need Medicare Part A and/or Part B If I Am Still Working?

    by | Sep 18, 2025 | Original Medicare, Rules & Enrollment

    Of course, turning 65 doesn’t mean you have to retire—but it does mean Medicare eligibility begins, and many people still wonder:

    “If I’m still working and have health insurance through my employer, do I need to enroll in Medicare when I turn 65?”

    The answer depends on several factors—including your employer size, your current health coverage, and whether you’ve already started Social Security. At Emerald Medicare, we help clients evaluate these decisions every day to avoid penalties, gaps, or unnecessary costs.

    Let’s break it down…

    ✅ Start with Medicare Part A: Most People Enroll

    Medicare Part A (hospital insurance) is premium-free for most people and generally covers inpatient hospital stays, skilled nursing, and hospice care.

    • If your employer has coverage and you’re still working, you can usually enroll in Part A at 65 without any downside.
    • HOWEVER—if you’re contributing to a Health Savings Account (HSA), you may want to delay Part A to avoid tax issues.

    🧾 What About Part B? It Depends on Employer Size

    Medicare Part B covers outpatient care, doctor visits, and preventive services. Unlike Part A, you do pay a monthly premium for Part B—so enrolling unnecessarily could cost you.

    IF YOUR EMPLOYER HAS 20 OR MORE EMPLOYEES:

    • You can delay enrolling in Part B without penalty.
    • Your employer coverage remains primary, and Medicare is secondary.
    • You’ll qualify for a Special Enrollment Period (SEP) when you retire or lose coverage—no late penalty.

    IF YOUR EMPLOYER HAS FEWER THAN 20 EMPLOYEES:

    • You must enroll in Medicare Part A and B when first eligible.
    • In this case, Medicare becomes your primary insurance, and your employer plan pays second—or not at all.
    • Failing to enroll could leave you uninsured and/or penalized.

    Always check with your HR department—don’t assume your employer coverage counts as “creditable” for Medicare.

    💼 Still Working with an HSA? Be Careful

    If you’re contributing to a Health Savings Account (HSA) and you enroll in any part of Medicare, including Part A, you must stop HSA contributions.

    • Enrollment in Medicare (even Part A) disqualifies you from contributing.
    • Retroactive Part A enrollment (up to 6 months) can create IRS penalties if you’re not careful.
    • We typically recommend stopping HSA contributions at least 6 months before you apply for Medicare.

    📍 Why It Matters

    Making the wrong choice about when to enroll can lead to:

    • Late enrollment penalties
    • Gaps in coverage
    • Unexpected bills if Medicare should have paid primary
    • Tax consequences for HSA users

    ✅ When to Enroll (or Delay) Original Medicare: A Quick Recap

    Situation Part A Part B
    Employer has 20+ employees, no HSA Usually enroll Delay OK
    Employer has fewer than 20 employees Enroll Enroll
    Still working and using an HSA Delay Delay
    Retiring soon or leaving coverage Enroll Enroll (within 8 months of losing coverage)

    Click below to schedule an appointment with one of our Medicare Experts.

    Or, Contact Us
    📞 (888) 683-6372 or (845) 358-1220
    📧 office@emeraldmedicare.com

    Mark Brownstein, CSA® | Calendly

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