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A hospital benefit period is one of those pieces in the Medicare jigsaw puzzle that people find especially difficult to understand. And that’s not in the least surprising. Wouldn’t you think that a benefit period is simply a length of time during which Medicare will cover your care after you’re admitted to the hospital? But no, it doesn’t work like that.
Medicare officials explain that a benefit period begins on the day you’re admitted and ends when you’ve been out of the hospital for 60 days in a row. If you leave the hospital on a certain date (for example, May 5) but are readmitted within 60 days of that date (say, June 23), you’re still within the same benefit period. But if you go back into the hospital more than 60 days from the time you left (say, July 17), you’re then in a new benefit period. The difference between the two has an impact on your costs — perhaps to the tune of hundreds of dollars.
This issue is made more complicated by the fact that any time you spend in a skilled nursing facility (where you may go for continuing care after being discharged from the hospital) also counts toward a benefit period but has different rules and out-of-pocket costs. And — wouldn’t you just know? — expenses in benefit periods are likely to be different depending on whether you’re enrolled in traditional Medicare or a Medicare Advantage (MA) plan.
Hospital coverage in traditional Medicare
Here’s what you pay and what Medicare pays for hospital care in each separate benefit period:
- Days 1 through 60: You’re responsible for the first chunk of costs until you’ve met the Part A hospital deductible (a maximum $1,316 in 2017). After that, you pay nothing further for hospital care (bed, meals, and nursing services) during the same benefit period. (However, you still need to pay Part B co-pays for doctors’ services while you’re in the hospital.)
- Days 61 through 90: You pay a daily co-pay ($329 a day in 2017), regardless of whether you’ve stayed more than 60 consecutive days in the hospital or have been readmitted during the same benefit period.
- Beyond 90 days: You’re responsible for 100 percent of the costs — but you can draw on up to 60 lifetime reserve days for a hefty daily co-pay ($658 in 2017).
Medicare places no limit on how many benefit periods you can have. But after you’ve been out of the hospital for 60 days, you enter a new benefit period. So if you go back into the hospital then, you must meet a new Part A deductible (another $1,316 in 2017) before coverage kicks in again.
All Medigap policies provide extra coverage for hospital stays beyond 60 days, and several cover the whole Part A deductible.
Perhaps one source of confusion over benefit periods is that three of the rules involve a time frame of 60 days, yet each has a different meaning. So to be clear, here’s a quick primer:
- 60 days = the number of days you must have been out of the hospital or skilled nursing facility to qualify for a new benefit period
- 60 days = the maximum length of time that Medicare will cover 100 percent of your care in a hospital after you’ve met the deductible for each benefit period
- 60 days = the maximum number of lifetime reserve days that you can draw on to extend Medicare coverage for hospital care during one or more benefit periods
Skilled nursing care in traditional Medicare
The time spent in both the hospital and the SNF count toward a benefit period. And you must stay out of both for 60 days to qualify for a new benefit period.
But your share of the costs in an SNF is different from those listed in the preceding section for hospitals. In an SNF, in any one benefit period, you pay the following:
- Days 1 through 20: Nothing for bed, meals, and nursing care
- Days 21 through 100: A daily co-pay ($164.50 a day in 2017)
- Beyond 100 days: All costs
You can’t use any hospital lifetime reserve days to extend Medicare coverage in an SNF beyond 100 days in any one benefit period. However, you may get more coverage if you have a Medigap policy, long-term-care insurance, Medicaid coverage, or insurance from an employer or union. If you have one of these, check with your plan to see what SNF charges are covered.
Hospital and SNF coverage in Medicare Advantage plans
Medicare Advantage plans (such as HMOs and PPOs) also use Medicare benefit periods. But their charges for hospital and skilled nursing care vary widely from plan to plan, and they may also be very different from those in traditional Medicare.
Typically, Medicare Advantage plans don’t charge the Part A deductible for each benefit period. Most often, they charge a flat-dollar daily co-pay for the first several days (which can vary from $100 to over $500 a day) and nothing after that for the remainder of the benefit period. Also, Medicare Advantage plans may have different rules from those in the traditional program. If you’re in one of these plans, check your coverage documents or call the plan to be sure of its rules and what a hospital or SNF stay would cost.