Q. 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.
A. A hospital benefit period is one of those aspects of Medicare coverage that many people find especially difficult to understand. Which isn’t surprising. You’d 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 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.
So if you’ve left the hospital on a certain day, and are then readmitted before 60 days from that date is up, 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 an impact on your costs.
The issue is 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—counts toward a benefit period but has slightly different rules and costs. Also costs in benefit periods may be different depending on whether you’re enrolled in the traditional Medicare program or in a Medicare health plan.
Hospital coverage in traditional Medicare
Here is what you pay and what Medicare pays for hospital care in each separate benefit period:
- You are responsible for the first slice of hospital bills—up to a maximum $1,216 in 2014. 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. (But you 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 2014 this copay is $304 a day.
- Beyond 90 days of inpatient hospital care in the same benefit period, you are responsible for 100 percent 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 2014, your share of the cost is $608 a day. But if you have any type of Medicare supplemental insurance (also known as medigap), your policy covers an additional 365 life-time reserve days, with no copays.
Once you’ve been out of the hospital for 60 days, you start a new benefit period if you need to be admitted again, even if it’s for the same illness or injury that took you there before. And with each new period, you get the same benefits and pay the same set of charges as above, according to how long you need hospital care. This includes paying the Part A deductible again, unless you have a medigap policy that covers it.
There is no limit to the number of benefit periods you can receive in general hospitals for any kind of inpatient care. However, if you are hospitalized in a specialized psychiatric facility for mental health care, Medicare covers only 190 days in your lifetime. (See: “Ask Ms. Medicare: Medicare’s Coverage of Mental Health Services.”)
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 cheat sheet:
- 60 days = the number of days you must have been out of a hospital or skilled nursing facility in order 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 in any one benefit period.