Two-Midnight Rule: New FAQ Document Offers Greater Clarity for MA Organizations

Due to ongoing confusion on the application of the “Two-Midnight Rule” for Medicare Advantage Organizations (MAOs), Highmark developed a frequently asked questions (FAQ) document that offers clarity around clinical review for inpatient hospital admittance.

What is the Two-Midnight Rule (TMR)?

The TMR provides guidance for inpatient hospital admittance and includes two key elements, a benchmark and a presumption:

1. Two-Midnight Benchmark: A Medicare Advantage plan must provide coverage (by furnishing, arranging, or paying) for an inpatient admission when — based on consideration of complex medical factors documented in the medical record — the admitting physician expects the patient to require hospital care that crosses two midnights.
2. Two-Midnight Presumption: Hospital stays that cross two midnights after a patient has been admitted as an inpatient generally are considered payable under Part A and insulated from traditional or original Medicare reviews.

How does the Two-Midnight Rule apply to MAOs?

Before 2024, the TMR applied only to traditional Medicare. In the 2024 Final Rule, the TMR generally applies to MAOs, bringing them into closer alignment with traditional Medicare.

However, Centers for Medicare and Medicaid Services (CMS) instructions to traditional Medicare contractors regarding how to prioritize medical claim reviews do not apply to MAOs, as the CY2024 Medicare Advantage/Prescription Drug Final Rule makes clear:

• MA plans are allowed to perform clinical review of inpatient hospital stays for medical necessity even if the Two-Midnight Presumption threshold is met.

The Rule is clear that the Two-Midnight Presumption applies only to traditional Medicare and is not always applicable to MAOs.

For more information, see the Two-Midnight Rule FAQs now available on the Provider Resource Center's Electronic Claims page.