What is a benefit period?

Emily WhicheloeDear Marci0 Comments

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Dear Marci,
I have Original Medicare and am going to get inpatient surgery at a hospital soon. I want to understand some of the costs I may have. Can you explain what a benefit period is? Ramona (Watertown, SD)

Dear Ramona,

This is a common question. A benefit period is the way the Original Medicare program measures your use of inpatient hospital and skilled nursing facility (SNF) services. It begins the day that you enter a hospital or SNF and ends when you have not received inpatient hospital or Medicare-covered skilled care in a SNF for 60 days in a row. The benefit period is not tied to the calendar year.

If you go into the hospital or SNF after one benefit period has ended (more than 60 days after you left), a new benefit period begins. There is no limit to the number of benefit periods you can have, or how long a benefit period can be.

Benefit periods also affect how much you may pay for your inpatient hospital or SNF stay. You must meet your Part A deductible at the beginning of each benefit period as well as pay a daily coinsurance depending on how many days you stay at the hospital or SNF during one benefit period.

After you meet your Part A deductible at the beginning of the benefit period, the first 60 days of your inpatient hospital stay are covered with no daily coinsurance. Similarly, if you qualify for a Medicare-covered SNF stay, you will pay nothing for the first 20 days of your SNF stay within a benefit period.

In 2016, Original Medicare Part A costs for hospital and SNF stays are:

  • Deductible: $1,288 for each benefit period
  • Hospital coinsurance: $0 for the first 60 days of inpatient care each benefit period; $322 per day for days 61-90
  • Skilled nursing facility coinsurance: $0 for the first 20 days of inpatient care each benefit period; $161 per day for days 21-100  

Let’s say you enter the hospital as an inpatient on May 1 and go home on May 15 (14 days in the hospital). If you need to go back to the hospital on June 30 (46 days out of the hospital) for 3 days, you are still in the same benefit period because you have not spent more than 60 days out of the hospital or SNF. You will also not have to pay another hospital deductible. In addition, since you will be on days 15-18 of your hospital benefit, you will not have to pay any coinsurance either.

If you have questions about where you are in your benefit period, look at your most recent Medicare Summary Notice (MSN), which is a summary of health care services you have received over the past three months. If you do not have your most recent MSN, you can call 1-800-MEDICARE to request a copy.  

– Marci

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