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Hospital & Skilled Nursing Benefit Periods Defined

August 7, 2017

 

What does a "hospital benefit period" mean?  

“I'm about to go into the hospital for major surgery and will need rehabilitation therapy afterward.  I'm concerned about how long Medicare will pay for my care”.   This is a question I hear quite frequently because it is one of those aspects of Medicare coverage that many people find especially difficult to understand.  It would seem logical to think that a benefit period would simply be a length of time during which Medicare would cover your care if you're admitted to the hospital.  But it doesn't work like this.  A benefit period begins on the day you're “admitted” into the hospital and ends when you've been out of the hospital for 60 days in a row.  

 

Pay special attention to the word “admitted”.  Many times patients are not aware of the fact that they have not actually been admitted into the hospital, but are instead “under observation”.  Being under observation is considered an outpatient benefit and will not count toward the actual inpatient benefit period.  To give an example, let's say you've been taken to the hospital and you’ve gone through Triage.  Your assumption would be that you are being admitted into the hospital.  This is not always the case, and has caused much controversy recently, because many times patients are not told or given a choice about the matter and this can cause a big consequence with regard to your out of pocket costs.  With this said, it is always important to take charge of your care and ask questions to determine your status.

 

Now that you are aware of your status as “inpatient”, let’s say that you’ve left the hospital on a certain day and you're then readmitted before 60 days from that first admittance date is up.  In this case you're still within the same benefit period.  But if you go back into the hospital after that 60th day, you're then in a new benefit period.  The difference between the two has a big impact on your costs.    The issue is even more complicated by the fact that any time spent in a skilled nursing facility - where you may go for continuing care or rehab services after your discharge from the hospital - count toward a benefit period but has slightly different rules and costs (see below - Skilled Nursing).   Also note that costs in a benefit period may be lower depending on whether you choose to include a Medicare Supplement insurance plan (aka Medigap) to your Original Medicare Parts A&B.   

 

Hospital Coverage with Original Medicare Part A:  Below are the out of pocket costs you would pay with Original Medicare Part A in each separate benefit period if you do not have additional supplemental coverage.   

 

You are responsible for the first slice of hospital bills - up to a maximum of $1316 in 2017.  This is the Medicare Part A hospital deductible which, unlike other deductibles, applies to each new benefit period and not just to your first hospital stay of the year.   Once you've paid that deductible Medicare picks up the rest of the tab for hospital care (bed, meals and nursing services) for a stay of up to 60 days after admission.  If you stay in the hospital for all of this time, or are discharged sooner but return during the same benefit period (even for a different medical problem), you pay nothing further for this care.   NOTE: You will still pay for physicians' care and certain other services under your Part B benefits - usually 20% percent of the Medicare approved costs.  If you need to spend more than 60 days in the hospital, whether consecutively or because of readmission during the same benefit period, you pay a daily copayment for days 61 through 90.  In 2017 this copay is $329/day.  Beyond 90 days of inpatient hospital care in the same benefit period, you are responsible for 100% of the costs.  However, Medicare allows you a further 60 days of "lifetime reserve" days.  This means that for the rest of your life you can draw on any of these 60 days, but no more, to extend Medicare coverage in any benefit period.  In 2017 your share of the cost is $658/day.  Again, important to note is that if you have any type of Medicare supplement insurance plan (aka Medigap), your policy covers an additional 365 lifetime reserve days, with no copays.    

 

Skilled Nursing with Original Medicare

Original Medicare Parts A & B offers some benefits for Skilled Nursing Facility (SN