- Medicare benefit periods usually involve Part A (hospital care).
- A period begins with an inpatient stay and ends after you’ve been out of the facility for at least 60 days.
- You’ll pay different amounts based on how long you’ve been staying at an inpatient facility or facilities.
A Medicare benefit period is how Medicare measures and pays for your care when you’re an inpatient at a hospital or skilled nursing facility. Over the course of your benefit period, the amount you may need to pay for your care will vary.
Then, when you haven’t been in the hospital or a skilled nursing facility for at least 60 days after being discharged, the benefit period ends.
Keep reading to learn more about Medicare benefit periods and how they affect the amount you’ll pay for inpatient care.
Medicare benefit periods mostly pertain to Part A, which is the part of original Medicare that covers hospital and skilled nursing facility care. Medicare defines benefit periods to help you identify your portion of the costs. This amount is based on the length of your stay.
Some of the facilities that Medicare Part A benefits apply to include:
If you have Medicare Advantage (Part C) instead of original Medicare, your benefit periods may differ from those in Medicare Part A. We’ll go over those details a bit later.
Let’s take a look at how the benefit periods in Medicare Part A are organized. If you need to stay in a hospital for at least two midnights, you enter a benefit period.
Here’s what you’ll pay in 2021:
- Initial deductible. Your deductible during each benefit period is $1,484. After you pay this amount, Medicare starts covering the costs.
- Days 1 through 60. For the first 60 days that you’re an inpatient, you’ll pay $0 coinsurance during this benefit period.
- Days 61 through 90. During this period, you’ll pay a $371 daily coinsurance cost for your care.
- Day 91 and up. After 90 days, you’ll start to use your lifetime reserve days. These are 60 additional days beyond day 90 that you can use over your lifetime. They can be applied to multiple benefit periods. For each lifetime reserve day used, you’ll pay $742 in coinsurance. Once you use up your 60 days, you’ll be responsible for all costs associated with inpatient stays that last longer than 90 days.
An estimated 40 percent of people with Medicare require post-acute care after a hospital stay – for example, at a skilled nursing facility. Coinsurance costs work a little differently when you’re admitted to a skilled nursing facility. Here is the breakdown of those costs in 2021:
- Initial deductible. The same Part A deductible of $1,484 applies during each benefit period is $1,484.
- Days 1 through 20. For the first 20 days, you’ll pay $0 coinsurance for your stay in a skilled nursing facility.
- Days 21 through 100. You’ll pay a $185.50 daily coinsurance cost for your care during this period.
- Day 101 and beyond. You’re responsible for all costs.
Costs can vary from year to year, based on changes to Medicare. It’s important to check each year to see if the deductible and copayments have changed, so you can know what to expect.
According to a 2019 retrospective study, benefit periods are meant to reduce excessive or unnecessarily long stays in a hospital or healthcare facility. Medicare doesn’t cover long-term care.
Benefit periods can definitely get a little confusing. Here are a few example scenarios to help explain how they work.
Scenario 1: New benefit period
You get sick and need to go to the hospital. You haven’t been in a hospital or skilled nursing facility for 60 days. This means you’re starting a new benefit period as soon as you’re admitted as in inpatient.
Your benefits will start as a blank slate, meaning you’ll first pay your deductible. Then, coinsurance fees will begin after you’ve been in the hospital for 60 days.
Scenario 2: Transfer to a different facility
After a fall, you need inpatient hospital care for 5 days. Your doctor sends you to a skilled nursing facility for rehabilitation on day 6, so you can get stronger before you go home.
When you’re transferred to the skilled nursing facility, you’re in the same benefit period as when you were in the hospital for the fall.
You will continue paying toward the deductible that applied at the hospital, unless you already met it. At that point, you’d have 55 days before coinsurance fees kicked in.
Scenario 3: Entering back into a benefit period
You’re in the hospital for about 10 days and then are discharged home. Unfortunately, you get sick again 30 days after you were discharged. You go back to the hospital and require another inpatient stay.
Because you were admitted back to the hospital within 60 days of your previous visit, you’re still in the same benefit period as before.
Again, you’ll be paying into the same deductible as the first visit, unless it was already met during that time. It will count as day 11 of your coinsurance-free coverage (up to the limit of 60 days before daily costs begin).
You can have unlimited benefit periods over the course of the time that you have Medicare. There’s no limit per calendar year.
If you have Medicare Advantage (Part C), your benefit periods may be different than with Medicare Part A.
These periods can vary, so it’s important to read your plan documents thoroughly. When you signed up for your plan, you should have received an explanation of your benefits. These documents will describe your benefit periods.
Some plans charge a copayment for a hospital stay or different copayments for a skilled nursing facility and allow for unlimited days in a benefit period. Other plans may charge a certain amount for the first 5 days spent in a hospital, then nothing for another set of days during a benefit period.
There are many variations in Medicare Advantage plans, so it’s best to read your coverage documents for details. You can also call your plan if you have specific questions.
If you’re already in a hospital, you can ask to speak with a case worker or benefits specialist, who can help you understand your estimate costs.
Certainly, Medicare benefit periods can be confusing. If you have specific questions regarding Medicare Part A costs and how a service you need will be covered, you can contact these sources for help:
- Medicare. You can call Medicare directly at 800-MEDICARE with a specific question related to your benefit periods.
- State Health Insurance Assistance Program (SHIP). SHIP is dedicated to providing help on the state and local level for questions about Medicare. To find your state’s contact information, click here.
If you have Medicare Advantage (Part C) plan or a supplemental policy, such as Medigap, contact your insurance provider. It may be helpful to have examples of specific situations, dates, and times to help define your benefit periods.
- Medicare benefit periods include all inpatient care, including at a hospital or skilled nursing facility.
- When you’ve been out of an inpatient facility for at least 60 days, you’ll start a new benefit period.
- An unlimited number of benefit periods can occur within a year and within your lifetime.
- Medicare Advantage policies have different rules entirely for their benefit periods and costs.
This article was updated on November 20, 2020, to reflect 2021 Medicare information.
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