Guide to explaining the Medicare hospital benefit period
Under Medicare, the hospital benefit period starts once you’ve been admitted to the hospital and expires once you’ve been at home for 60 consecutive days. Say that you’ve been released from the hospital on a particular day, but you had to go back before that 60-day period has ended. Your stay will still fall within the hospital benefit period. Unfortunately, if you have to return to the hospital after that period has expired, it’s considered to be another benefit period. The differences between each situation will affect your medical costs.
This situation is made more difficult if you have to be admitted into a nursing facility or convalescent center in order to receive additional care or rehabilitation aid once you’ve been released from the hospital. This stay is considered to be part of the hospital benefit period, but the rules and fees are a bit different. Furthermore, the costs you accrue for each period can vary, based on whether you’re covered by Medicare’s traditional program or a Medicare Advantage plan.
Traditional Medicare hospital coverage
Here is a breakdown of how much Medicare will cover and how much you’ll owe out-of-pocket for individual hospital benefit periods:
- You will be expected to pay for the initial cost of your hospital stay up to a limit of $1,288. This is your hospital deductible for Medicare Part A. As opposed to other Medicare deductibles, it begins anew with every hospital benefit period, rather than your first admission to the hospital each year.
- After this deductible is met, Medicare will start to cover the remainder of your costs for in-hospital services, such as food, nursing and your bed, for a limit of 60 days following your date of admission. There is $0 copay or coinsurance during this period of time as well. Should you spend the entire period in the hospital, or if you’re released early but are readmitted within the same period, even if it’s for a separate issue, you will not owe any additional money for the services rendered. However, you will still be required to cover doctor care and some other services if you have a plan under Medicare Part B. This typically consists of 20 percent of the fees approved by Medicare.
- Should you be required to stay in the hospital past the 60-day mark, either in a row or due to another incident within the same hospital benefit period, you will be charged a daily fee or coinsurance for every additional day in the hospital, starting on day 61 and up to day 90. The standard coinsurance amount is $322 a day.
- After day 90, a person’s lifetime reserve days will kick in. A person has 60 lifetime reserve days, which can be used at any time during their lifetime. Once they use all 60 days, they will never receive additional lifetime reserve days. The Medicare recipient is charged a daily coinsurance for any lifetime reserve days used. The standard coinsurance amount is $644 per day. If you’re enrolled in a supplemental Medicare insurance program, also known as “Medigap,” you will receive another 365 days in your lifetime reserve with no additional copayments.
- After day 90 in a benefit period, and if the person has no more lifetime reserve days available to use, the Medicare recipient is responsible to pay all of the costs associated with their hospital stay.
- After you’ve spent 60 days out of the hospital, your benefit period will start all over again. At the start of each new period, you will receive the same benefits and owe the same coinsurance amounts as mentioned earlier, depending on how long you require hospitalization.
- No ceiling is imposed on how many benefit periods you can have for inpatient mental health treatment in a general hospital or specialty facility, such as a psychiatric hospital. That said, Medicare does impose a lifetime limit of 190 days.
Easily the greatest causes of misunderstanding with hospital benefit periods are three rules that include a span of 60 days. However, each rule means something different. In order to help you make better sense of this, here’s a breakdown.
- 60 days: How many days you are required to be out of the hospital or after-care facility to become eligible for another hospital benefit period.
- 60 days: The maximum number of days that Medicare will pay for all of your inpatient hospital care once you’ve paid your deductible for every new benefit period.
- 60 days: The upper limit of days you have in your lifetime reserve that can be used to draw out your Medicare coverage for hospitalization during a single benefit period.
Speak with a Healthcare Professional (800) 485-6202 TTY 711
Skilled Nursing with Traditional Medicare Coverage
In an Original Medicare plan, you have to stay for a minimum of three days, or more than two nights, to officially be admitted as a patient in a hospital. Only then will Medicare start to pay for your care in a skilled nursing center for additional treatment, like physical therapy or for regular IV injections. The amount of time you spend in the hospital as well as the skilled nursing center will be counted as part of your hospital benefit period. Furthermore, you are required to have spent 60 days out of each in order to be eligible for another benefit period.
However, the portion you are expected to pay for the costs of a skilled nursing center differs from the portion you pay for hospital care. In facilities like these, you must pay in any given benefit period:
- $0 for your room, bed, food and care for all days up to day 20
- A daily coinsurance rate of $161 for days 21 through 100
- All costs starting on day 101
You are not allowed to use your lifetime reserve days to prolong your Medicare insurance for your stay in a skilled nursing center after 100 days is up in a single hospital benefit period. Nonetheless, you might be able to obtain additional coverage if you’re enrolled under a supplemental policy, long-term care insurance or employer-provided insurance. You should refer to your individual policy to find out what costs will be covered for skilled nursing.
Options with Medicare Advantage
You are subject to Medicare’s hospital benefit periods if you have a Medicare Advantage health plan. However, the costs for skilled nursing and hospital care vary significantly between plans and can be quite different from traditional Medicare.
Nearly all Medicare Advantage policies feature varying costs. Furthermore, each plan may have rules that differ from the ones found under Original Medicare policies. For instance, with most policies, you don’t have to be hospitalized for three days before you can be moved to a skilled nursing center. If you have one of these policies, refer to the documentation for your coverage. You could also call your provider to find out exactly what hospitalization or a stay in a skilled nursing center will cost you as well as the rules surrounding it.