What is Considered a Benefit Period?

If you’re on Medicare and you need a stay at a hospital or skilled nursing facility (SNF), you may hear the words “benefit period.” Medicare uses this term as a way to measure your use of hospital or skilled nursing facility care. Under Medicare Part A (inpatient hospital or skilled nursing facility coverage), a benefit period starts on the day you’re admitted as an inpatient to a hospital or SNF and ends when you’ve left and haven’t received any inpatient care in a hospital or SNF for 60 days in a row. 

If you’re an inpatient in a hospital or skilled nursing facility again after a benefit period has ended, a new benefit period begins for your second inpatient stay, even if the second stay is related to the first one. For example, let’s say you were an inpatient in the hospital for 10 days and then found yourself back in the hospital 70 days after you were discharged—a new benefit period would begin with your second hospital admission. 

Conditions for getting Medicare SNF coverage
Medicare doesn’t pay for long-term care at skilled nursing facilities, as it’s considered custodial rather than medical. However, if specific conditions are met, Medicare will pay for short-term care at these facilities.

Those conditions are:

  • Your benefit period must begin with an inpatient stay at a hospital for at least three days. 
  • When it’s time for you to leave the hospital, your physician must order ongoing inpatient care at a Medicare-certified SNF. Typically, you must be admitted to an SNF within 30 days of leaving the hospital.

How much does Medicare pay for SNF stays per benefit period?
There are no limits on the number of benefit periods you can have. However, for each benefit period, you have to pay the deductible for an inpatient stay. 

How much Medicare pays varies throughout each benefit period. With Original Medicare, the first 20 days of your benefit period are fully covered. For days 21 to 100, you pay a per-day coinsurance. From day 101 on, you pay all costs. 

The coinsurance cost is the amount you’re responsible for paying after Medicare has paid its portion and you have met your deductible. Along with premiums and deductibles, the coinsurance rate is adjusted yearly, so it may vary from one year to the next. Your coinsurance and other costs may be covered if you have a Medigap or Medicare Advantage policy, depending on the specifics of your plan.

After you’ve spent 100 days in an SNF or hospital, your Medicare coverage ends for that specific benefit period. To get Medicare coverage for an SNF stays once again, you have to begin a new benefit period. 

For example, say you stayed at an SNF for 100 days and then went home. Let’s call this benefit period A. Benefit period A ends 60 consecutive days after your discharge from the SNF. If you’re admitted as an inpatient to a hospital on day 61, you begin a new benefit period (benefit period B). If you’re then admitted as an inpatient at a skilled nursing facility, you follow the same coverage schedule as you did in the previous benefit period (benefit period A): your first 20 days at the SNF are fully covered, you pay a per-day coinsurance for days 21 to 100, and you pay all costs after that. 

Special COVID-19 pandemic provisions
Currently, due to the COVID-19 pandemic, Medicare has instituted some flexibility to SNF coverage. While the pandemic continues, if, due to a medical condition, you’re not able to be in your home, you may be able to get SNF care without meeting the minimum three-day hospital admission requirement. Also, you may be able to get renewed SNF coverage without having to begin a new benefit period. Check medicare.gov for updated information on these changes.

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