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Congressional Daily Record
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Issued
May 21, 2026
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Download official Senate Record PDFReturn to issue contextMs. COLLINS. Mr. President, I rise today to introduce the Improving Access to Medicare Coverage Act, to help protect American seniors from high medical costs when they need skilled nursing care after hospitalization. I am pleased to be joined on this bill by my colleague from Vermont Senator Welch.
which requires beneficiaries to have an “inpatient” hospital stay of at least 3 days before Medicare will cover posthospitalization skilled nursing care. Patients who receive hospital care under “observation status” do not qualify for this benefit, even if their hospital stay lasts longer than 3 days.
have never been admitted as inpatients. They just know that they are in the hospital. If they are admitted later to a skilled nursing facility for follow-up care, they may be shocked to learn that they will be liable for out-of-pocket costs totaling thousands of dollars. Some Medicare beneficiaries may be foregoing skilled nursing or rehabilitation care altogether because they simply cannot afford to pay the out-of-pocket costs.
“observation status” at a hospital in Maine, but who needed and received acute care at that hospital. She was discharged to a skilled nursing care facility, which was also appropriate for her condition, but because of Medicare's 3-day rule and its treatment of “observation status,” Medicare refused to pay for her skilled nursing care. She was stuck with a bill of more than $56,000.00 for care she needed. That is unfair.
In another example, shared with me by Dr. Claudia Geyer, the chief medical officer at Central Maine Medical Center in Lewiston, ME, a 90- year-old man with a fractured pelvis was denied Medicare coverage for skilled nursing care because he was admitted to the hospital under observation status. This gentleman had no way of paying for skilled nursing care on his own, so he had to remain in the hospital, costing Medicare more—and more important—not getting the physical therapy he needed to regain his strength and recover. As a result, he slowly weakened, suffered cognitive declines, and deteriorated to the point where he needed extensive care that may have been avoidable.
Dr. Geyer also cared for a 99-year-old patient who was living independently with the support of her family and had never before required hospitalization. This patient used a walker in her home but suffered a fall and broke her wrist. She was stabilized in the hospital and was expected to make a full recovery, but first she needed high quality skilled rehab, and she could not use her walker while her wrist healed. Despite almost a century of good health and almost no cost to Medicare in her lifetime, she and her family were horrified when they were told that CMS would not cover her skilled nursing expenses due to the hospitalization being deemed an “observation stay.”
be discharged from the hospital to skilled nursing homes as soon as it was medically appropriate. That waiver ensured that patients weren't hospitalized longer than truly necessary and also protected seniors from unexpected and unfair bills. But as soon as the waiver ended in 2023, patients started staying in the hospital longer for no medical reason. In fact, a study published in January by the Brown University School of Public Health showed that Medicare paid for 2,000 more inpatient days in the month following the end of the waiver just because of this rule. If our aim is to improve the quality of care our seniors receive while avoiding unnecessary expenses, allowing this waiver to expire has taken us in the wrong direction.
the waiver by deeming time spent in observation status as inpatient care for the purpose of Medicare's 3-day prior hospital stay requirement for skilled nursing care.
Medicine, the American Health Care Association, and more than 30 other organizations that represent seniors and their health care needs.
Mr. President, I ask unanimous consent that letters from these organizations be printed in the Record immediately following my remarks.
health and getting well, not on how they were admitted. The bill we are reintroducing advances that goal by helping insulate older Americans from undue out-of-pocket costs while ensuring that they get the care they need. I urge my colleagues to support it.
April 22, 2026.
Hon. Susan Collins,
U.S. Senate,
Washington, DC.
Dear Senator Collins: On behalf of the undersigned
organizations, we write to thank you for introducing the
Senate version of the Improving Access fo Medicare Coverage
Act of 2025. This bipartisan Legislation would ensure that
Medicare beneficiaries can access needed skilled nursing
facility (SNF) care by counting time spent in hospital
observation status toward the existing three-day hospital
stay requirement.
For decades, Medicare has required beneficiaries to have a
three-day inpatient hospital stay to qualify for SNF
coverage. However, current hospital practices increasingly
classify patients under “observation status,” even when
they receive the same care as admitted inpatients—often for
multiple days. Because observation days do not count toward
the qualifying stay, many beneficiaries are denied access to
SNF care or face significant and unexpected out-of-pocket
costs.
This issue is particularly significant for Maine. In 2024,
Maine led the nation with the highest percentage of state
residents ages 65 and older (23.5%). Add that to the fact
that many of you rural constituents across the state often
rely on seamless transitions from hospital to SNF settings,
and administrative barriers like the observation status
policy can delay care, increase costs, and create unnecessary
hardship for patients and their families. Ensuring timely
access to SNF services is essential to maintaining continuity
of care, especially in areas where provider options may be
limited and distances between care settings are greater.
Your legislation offers a common-sense solution by ensuring
that all days a patient spends in the hospital—whether
classified as inpatient or observation—count toward the
threeday requirement. This policy change would better align
traditional Medicare with modern care delivery and with
existing Medicare Advantage, Accountable Care Organization,
and bundled payment models, which already allow greater
flexibility in accessing SNF services.
Importantly, evidence demonstrates that this reform would
improve beneficiary access to post-acute care without
significantly increasing costs to the Medicare program.
Analysis estimates a modest net impact on the Medicare Trust
Fund—approximately $191 million over ten years—while
expanding access to necessary care for thousands of
beneficiaries each year.
This legislation is especially important for vulnerable
populations. Beneficiaries who lack access to alternative
Medicare models are disproportionately affected by the
current policy and may be unable to receive appropriate post-
acute care despite medically necessary hospital stays.
Research also shows that reinstating the strict three-day
inpatient requirement can lead to longer hospital stays
without improving patient outcomes, increasing overall costs
while creating unnecessary barriers to care.
For Maine's seniors, families, and providers, this
legislation would remove an outdated barrier and support more
efficient, patient-centered care transitions—helping ensure
that beneficiaries can recover in the most appropriate
setting without avoidable financial strain.
Again, we thank you for your introduction of the Improving
Access to Medicare Coverage Act and look forward to working
with you and other members of the Senate to ensure that
Medicare beneficiaries receive timely access to the post-
acute care they need.
Thank you for your leadership and consideration.
Sincerely,
ADVION (formerly National; Association for the Support of
Long Term Care); Aging Life Care Association; Alliance for
Retired Americans; American Academy of Emergency Medicine;
American Association of Healthcare, Administrative Management
(AAHAM); American Association of Post Acute Care; Nursing
(AAPACN); American Case Management Association (ACMA);
American College of Emergency Physicians (ACEP); American
College of Physician Advisors (ACPA), American Geriatric
Society (AGS); American Health Care Association (AHCA);
American Medical Association; American Physical Therapy
Association (APTA); Association of Jewish Aging Services
(AJAS; Catholic Health Association of the United States
(CHA); Center for Medicare Advocacy; The Hartford Institute
Geriatric Nursing; The Jewish Federations of North America;
Justice in Aging; LeadingAge; Lutheran Services in America;
Medicare Rights Center; National Academy of Elder Law
Attorneys, Inc. (NAELA); National Association of Benefits and
Insurance Professionals (NABIP); National Association County
Health Facilities (NACHFa); National Association for State
Longterm Care Ombudsman Programs (NASOP); National Center for
Assisted Living (NCAL); National Committee to Preserve Social
Security & Medicare; The National Consumer Voice for Quality
Long-Term Care; National Council on Aging (NCOA); National
Transitions of Care Coalition (NTOCC); NJHSA—the Network of
Jewish Human Services Agencies; Post-Acute and Long-Term
Medical Association; Society of Hospital Medicine (SHM);
Special Needs Alliance; USAging.
Society of Hospital Medicine,
Philadelphia, PA.
Hon. Susan Collins,
United States Senate,
Washington, DC.
Dear Senator Collins: The Society of Hospital Medicine
(SHM), representing the nation's hospitalists, is pleased to
offer our support for the reintroduction of the Improving
Access to Medicare Coverage Act. This legislation will make
days spent in observation count towards Medicare's three-day
stay requirement for skilled nursing facility (SNF) coverage,
ensuring Medicare beneficiaries receive the quality care they
need without facing exorbitant and unexpected medical bills.
This legislation is an important first step to address
problems related to observation status and ensure
beneficiaries qualify for much-needed care.
Hospitalists are front-line physicians in America's acute
care hospitals. They focus on the general medical care of
hospitalized patients and manage the inpatient clinical care
of their patients. SHM estimates that hospitalists oversee
the vast majority of observation care to hospitalized
Medicare patients each year. As a result, our members are
uniquely positioned to understand and identify problems
related to current observation policies.
Observation care was meant to last fewer than 24 hours and
rarely span more than 48 hours; however, the incidence and
duration of observation stays has increased significantly
over the past fifteen years. While patients admitted into
observation receive nearly identical care to those in
inpatient care under Medicare Part A, observation is billed
as outpatient under Medicare Part B. As such, patients face
highly variable out-of-pocket costs (coinsurance),
particularly when they need post-acute care.
Time spent under observation does not count toward the
three-day inpatient stay requirement for Medicare SNF
coverage, observation is considered outpatient care. Patients
discharged from observation to SNFs faced with the choice
between extremely high, unexpected SNF bills and forgoing
necessary follow-up care. Furthermore, beneficiaries in the
most disadvantaged communities are more likely to have an
observation stay, to have a repeated observation stay within
30 days, and to experience long-term observation. The three-
day stay requirement
perpetuates existing healthcare access inequities. This
legislation would help address this disparity.
Additionally, the three-day stay waivers issued during the
COVID-19 public health emergency (PHE) empowered clinicians
to focus on patient needs, rather than an outdated
administrative policy. The three-day stay waiver helped
facilitate the Society of Hospital Medicine transfer of
patients based on their clinical needs, rather than a payment
policy, helping patients get the care they needed at the
appropriate level. Medicare expenditure data from the Centers
for Medicare and Medicaid Services (CMS) during the PHE shows
that expanding access to SNF coverage did not dramatically
increase spending or utilization. This PHE era policy
demonstrates how the current three day stay requirement is an
unnecessary impediment to SNF coverage.
The Improving Access to Medicare Coverage Act is an
important step to ensuring patient access to postacute care.
We need to pass legislation to begin eliminating bureaucratic
barriers to necessary medical care.
On behalf of SHM, thank you for reintroducing the Improving
Access to Medicare Coverage Act. SHM is pleased to offer our
support to help secure the passage of this legislation.
Sincerely,
Efren C. Manjarrez, MD, FACP, SFHM,
President.