Fundamentals of Medicare

Section 2: Medicare Basics

Medicare Part A

Table of Contents

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Medicare Part A

Medicare Part A is referred to as Hospital Insurance. It contains five major benefits:

  • Inpatient hospital services
  • Inpatient skilled care in a nursing facility
  • Skilled services provided through a home care program
  • Hospice care
  • Blood

It is interesting to note that even though this is known as the “hospital benefit,” only one of the benefits is actually rendered in the hospital. It is mostly for this reason that beneficiaries need to be educated regarding Part A coverage. Many do not understand that Part A “Hospital Insurance” only covers an overnight inpatient admission. Part A does not cover outpatient hospital services; those services are Part B services. Part A also does not cover any of the professional fees of physicians, radiologists, anesthesiologists and so on, who may see a patient during an inpatient stay.

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Benefit Periods—Medicare Part A

The benefit period was created to track a beneficiary’s use of the Medicare Part A benefit days, called “utilization.” A benefit period is also referred to as a “spell of illness.” Since the Medicare Part A benefit consists of facility inpatient stays that can vary in length from one day to a few years, the benefit period also sets a limit as to the number of days Medicare will pay for a beneficiary’s inpatient stay(s). This allows Medicare to have renewable benefit days; once the condition to end a benefit period has been met, a beneficiary receives a new benefit period with a new set of renewable days to use.

Since an inpatient stay can cross over year-end, it is impractical to have Part A benefits renew each calendar year. Consequently, the benefit period is not bound by the calendar year—a beneficiary can have many benefit periods in one year, or can have one benefit period that continues for many years.

A benefit period begins the first time a beneficiary enters a qualified hospital, SNF, or swing bed as an inpatient after his/her Medicare Part A entitlement begins.

Note: A beneficiary has a specific number of benefit days available per each benefit period. There is one set of days for hospital inpatient stays (150) and one set of days for SNF swing bed inpatient stays (100). The 150 hospital inpatient days and 100 SNFswing bed days are used separately; a hospital cannot use SNF swing bed days, nor can a SNF swing bed use hospital days. Even though each set of days is used separately (depending on the facility where the patient is an inpatient), both sets are linked to the same benefit period. Days used in either set can extend the benefit period.

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Ending a Benefit Period

An existing benefit period ends when 60 consecutive days have passed from a beneficiary’s date of discharge from being an inpatient of a hospital or a SNF swing bed. In addition, a benefit period can end when a beneficiary is an inpatient of a SNF swing bed but remains at a nonskilled level of care for 60 days in a row. This 60-consecutive-day period is sometimes referred to as a “break in spell,” “break in spell of illness” or being “facility-free” for 60 days.

If a Medicare beneficiary is admitted as an inpatient to a hospital or a SNF swing bed prior to the 60th consecutive day after his/her discharges from an inpatient stay at a hospital or a SNF/Swing bed, the beneficiary is not eligible for a new benefit period. When this occurs, the beneficiary will continue to use any days still remaining in his/her current benefit period. A beneficiary’s benefit period utilization will continue to draw from the same two sets of days as applicable until the 60-consecutive-day condition is met. Even when a beneficiary has no benefit days available in their current benefit period, called “benefits exhausted,” the benefit period will not end until the 60-consecutive-day condition is met.

If a Medicare beneficiary enters a facility as an inpatient and has been facility-free for 60 days, he/she is in a new benefit period with a full set of the renewable inpatient days available.

For more information regarding benefit periods, refer to the CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 3, Section 10.4.

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Benefit Period Examples

Who gets a new benefit period? It is 1/17/2022 and you work at Typical Hospital. Three patients are waiting to be admitted and it is up to you to decide whether these patients are eligible for a new benefit period. Here are the most recent inpatient summaries for each:

  • Mrs. Jones had an inpatient hospital stay from 3/3/2021–3/10/2021. She has not been an inpatient in any other hospital or skilled nursing facility since 3/10/2021.

Does Mrs. Jones get a new benefit period with this admission?
Yes, since it is now 1/17/2022, which is more than 60 days since 3/10/2021.

  • Mr. Wilson had an inpatient hospital stay from 12/14/2021–12/23/2021. He has not been an inpatient in any other hospital or skilled nursing facility since 12/23/2021.

Does Mr. Wilson get a new benefit period with this admission?
No, since it is now 1/17/2022, which is less than 60 days since 12/23/2021.

  • Mrs. Smith had an inpatient hospital stay from 9/30/2021–10/8/2021. She was transferred to a skilled nursing facility on 8/8/2021 and was at a covered level of care through when she was discharged home on 12/1/2021. She has not been an inpatient in any other hospital or skilled nursing facility since 12/1/2021.

Does Mrs. Smith get a new benefit period with this admission?
No, since it is now 1/17/2022, which is less than 60 days since 12/1/2021. Remember to count all inpatient stays, not just those at hospitals.

Revised 2/21/2022