Medicare’s 3-Day Rule Reinstatement Lengthened Hospital Stays Without Cost, Outcome Benefits

Reinstating the Medicare 3-day hospitalization requirement was associated with an increase in the proportion of hospital stays lasting at least 3 days, but it did not lead to discernible changes in skilled nursing facility (SNF) utilization, Medicare spending, or short-term adverse outcomes, according to a study published today in JAMA Internal Medicine.1

The post-pandemic reinstatement of Medicare’s 3-day rule lengthened hospital stays without affecting SNF use, spending, or short-term outcomes, raising questions about its value. | Image credit: Kzenon - stock.adobe.com

Pandemic Created a Rare Opportunity to Analyze Medicare’s 3-Day Rule

Under the Medicare 3-day hospital stay rule, SNF care is covered only for beneficiaries who were hospitalized for at least 3 consecutive days. The policy has historically remained unchanged outside alternative payment models but was temporarily waived during the COVID-19 pandemic before being reinstated on May 12, 2023, the day after the public health emergency ended.

This temporary waiver allowed the researchers to compare outcomes among individuals hospitalized before the rule was reinstated with those hospitalized on or after May 12, 2023, when the requirement returned. Specifically, the retrospective cohort study evaluated changes in inpatient length of stay, SNF utilization, Medicare spending, and short-term health outcomes among traditional Medicare beneficiaries following the reinstatement of the 3-day hospitalization requirement.

The analysis included all traditional Medicare beneficiaries 65 years and older who experienced an acute hospital stay between January 1, 2023, and November 31, 2023. The researchers used a regression discontinuity (RD) design to assess changes in outcomes associated with the rule’s reinstatement, with data analyzed between June and November 2025.

The primary outcomes were whether patients had 3 or more overnight hospital stays and whether they were admitted to an SNF within 30 days of hospital discharge. Additionally, secondary outcomes included 30-day hospital readmission, 30-day mortality, the number of SNF days among patients admitted to SNFs, and Medicare spending.

3-Day Rule Reinstatement Increased Length of Hospital Stays

The researchers identified 332,044 hospitalizations occurring within 28 days before May 12, 2023. The mean (SD) patient age was 78.3 (8.3) years, and most were female (53.8%; n = 178,547). In the 28 days following reinstatement, 338,375 hospitalizations were identified, with a similar mean (SD) age of 78.2 (8.3) years and an identical proportion of female patients (53.8%; n = 182,049).

Overall, 60.4% (n = 200,532) of hospitalizations lasted at least 3 days in the 4 weeks before reinstatement vs 62.0% (n = 209,860) in the 4 weeks afterward. Therefore, the rule reinstatement increased the probability of an inpatient stay lasting at least 3 days by 1.13 percentage points (95% CI, 0.61-1.66; P < .001), representing a 1.9% relative increase.

Among patients discharged to SNFs, 87.6% (n = 54,844) had hospital stays of at least 3 days before reinstatement compared with 96.0% (n = 61,731) afterward. For this subgroup, the rule reinstatement increased the probability of a qualifying hospital stay by 5.57 percentage points (95% CI, 4.91-6.24; P < .001), equating to a relative increase of 6.4%.

In contrast, there were no significant changes in the overall probability of SNF discharge, 30-day rehospitalization, 30-day mortality, Medicare spending, or total SNF days post-reinstatement. However, subgroup analyses showed that patients with dementia (2.20 percentage points; 95% CI, 0.62-3.78; P = .006; relative change, 3.1%) and those hospitalized with hip fractures (3.12 percentage points; 95% CI, 1.12-5.12; P = .002; relative change, 3.6%) experienced the largest increase in hospitalizations lasting at least 3 days following reinstatement.

Findings Could Prompt 3-Day Rule Reconsideration

The researchers acknowledged several limitations, including that the RD model estimates may not be generalizable beyond hospitalized traditional Medicare beneficiaries. They also noted that other policy changes associated with the end of the COVID-19 public health emergency could have introduced residual confounding. Still, the researchers expressed confidence in their findings and identified areas for further research.

“Because the policy appeared to prolong hospital stays without improving outcomes or achieving Medicare savings among inpatients, these findings raise questions regarding the value and continued relevance of a broadly applicable 3-day inpatient stay rule in the traditional Medicare program,” the authors concluded.

References

1. Chen Z, Trivedi AN, Rahman M, Kosar CM. Changes in inpatient and skilled nursing facility care after the Medicare 3-day rule reinstatement. JAMA Intern Med. Published online February 9, 2026. doi:10.1001/jamainternmed.2025.7838
2. Skilled nursing facility care. Medicare.gov. Accessed February 9, 2026. https://www.medicare.gov/coverage/skilled-nursing-facility-care