What Is a Medicare Hospital Benefit Period?

Skilled nursing care in traditional Medicare

Under the traditional Medicare program, you must spend at least three days in the hospital as an officially admitted patient before Medicare will cover your stay in an approved skilled nursing facility (SNF) for further needed care such as continuing intravenous injections or physical therapy. The time spent in both the hospital and the SNF count toward a benefit period. And you must have stayed out of both for 60 days to qualify for a new benefit period.

But your share of the costs in a skilled nursing facility is different from those listed above for hospitals. In such a facility, in any one benefit period you pay:

Nothing for your bed, board and care for days 1 through 20.

A daily copayment ($137.50 in 2010) for days 21 through 100.

All charges beyond 100 days.

You cannot use any hospital lifetime reserve days to extend Medicare coverage in a skilled nursing facility beyond 100 days in any one benefit period. However, you may get more coverage if you have a medigap policy, long-term care insurance, coverage from Medicaid or insurance from an employer or union. You need to check with your plan to see what skilled nursing charges are covered.

If you’re enrolled in a Medicare health plan

Medicare Advantage health plans (such as HMOs and PPOs) also use Medicare’s benefit periods. But their charges for hospital and skilled nursing care not only vary widely from plan to plan but may be very different from those in traditional Medicare. Here are a few examples among health plans in 2010 that illustrate the variations:

Plan 1 charges a flat $500 copay for each hospital stay and $350 for a skilled nursing facility stay, with no limit to the number of days in any one benefit period.

Plan 2 charges $250 a day for the first five days in the hospital and nothing more for up to 90 days in any one benefit period. For a skilled nursing facility stay, it charges $10 a day for the first 10 days and $85 a day for days 11 through 100.

Plan 3 charges $300 a day for the first seven days and nothing more for up to 90 days in any one benefit period. For a skilled nursing stay, it charges nothing for the first five days, $150 a day for days 6 through 20 and nothing for days 21 through 100.

Almost every Medicare Advantage plan has different charges. Also, plans may have different rules from those in the traditional Medicare program. Most plans, for example, don’t require you to spend three days in the hospital before being admitted to a skilled nursing facility.

If you’re enrolled in one of these plans, check your coverage documents or call the plan to be sure what a hospital or nursing facility stay would cost and what the rules are.

Patricia Barry is a senior editor at the AARP Bulletin.