(Medicare General Information, Eligibility, and Entitlement)

2021  1,484  371 742 185.50  2022  1,556  389 778 194.50  2023  1,600  400 800 200.00  2024  1,632  408 816 204.00  is synonymous with spell of illness.  Since the term "spell of illness" could connote a single illness or a particular "spell" of sickness, the term benefit period is used in communications with the public.  10.4.1 - Starting a Benefit Period  (Rev. 80, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  A benefit period begins with the first day (not included in a previous benefit period) on which a patient is furnished inpatient hospital or extended care services by a qualified provider in a month for which the patient is entitled to hospital insurance b enefits.   A provider qualified to start a benefit period is a hospital (including a psychiatric hospital) or SNF that meets all the requirements of the definition of such an institution.  A hospital which meets all requirements in Chapter 5, 20 of this manual is also a qualified hospital for purposes of beginning a benefit period when it furnishes the patient covered inpatient emergency services.  Thus, generally, the benefit period begins when covered inpatient services are initially furnished to an entitled individual.  However, the noncovered services furnished by a nonparticipating provider can begin a spell of illness only if the provider is a qualified provider.  A qualified provider is a hospital (including a psychiatric hospital) or a SNF  which meets all requirements in the definition of such an institution even though it may not be participating.  A qualified hospital in Canada or Mexico is also a qualified provider for purposes of beginning a benefit period when it furnishes covered inpa tient hospital services.  If a person is in a nonqualified institution and is subsequently transferred to a qualified hospital (general or psychiatric), his/her benefit period begins on admission to the qualified hospital.  Admission to a qualified SNF or to the SNF level of care in a swing- bed hospital begins a benefit period even though payment for the services cannot be made because the prior hospitalization or thirty -day transfer requirement has not been met.  It is also worth noting that the SNF benefits thirty -day transfer requirement has a medical appropriateness exception (described in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 8, section 20.2.2), under which the allowable interval between a beneficiarys discharge from a qualifying prior hospitalization and the initiation of SNF care can exceed the normal 30- day timeframe; moreover, in a situation where the allowable interval under this exception is 60 days  or longer, the subsequent commencement of extended care services in the SNF would serve to trigger the start of a new benefit period.  Inpatient care in a Religious Non- Medical Health Care Institution (whether as hospital or extended care services) can begin or prolong a benefit period.   10.4.2 - Ending a Benefit Period  (Rev. 80, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  The benefit period ends with the close of a period of 60 consecutive days during which the patient was neither an inpatient of a hospital nor of a SNF.  To determine the 60 consecutive day period, begin counting with the day the individual was discharged. (See 10.4.3.2 of this chapter for determining the end of a benefit period when an individual remains in a SNF.)   As noted in section 10.4, the term benefit period is synonymous with spell of illness.  However, t he statutory language (at 1861(a) of the Social Security Act) that describes a benefit period as a spell of illness is sometimes misunderstood to mean that a benefit period is linked to a particular medical episode or type of condition, so that the onse t of a new and entirely unrelated condition could serve to end a benefit period even in the absence of a 60 -day break in the beneficiarys inpatient statu s.  In fact, the onset of a new condition is not, in itself, relevant to the ending of a benefit period, which can occur only through a 60- day break in inpatient status, as described above.   10.4.3 - Definition of Hospital or SNF for Ending a Benefit Period  (Rev.10880, Issued: 08- 06-21, Effective: 11 -08- 21, Implementation: 11- 08-21)  It is important to note that a benefit period cannot end while a beneficiary is an inpatient (see 10.4.4) of an institution that meets the basic definition of a hospital at 1861(e)(1) of the Social Security Act (the Act), even if the hospital does not meet all of the additional requirements that are necessary for st arting a benefit period, as discussed further in 10.4.3.1 below (see also 1861(e) following (9) of the Act and the regulations at 42 CFR 409.60(b)(1)).  Similarly, a benefit period cannot end while a beneficiary is an inpatient (see 10.4.4) of an instit ution that meets the basic definition of a SNF at 1819(a)(1) of the Act, as discussed further in 10.4.3.2 below.  As noted in 2164 of the State Operations Manual (Pub. 100- 07), Chapter 2, all hospitals and SNFs that are Medicare- certified are automatically considered to meet the applicable basic definition in this context by reason of the Medicare certification itsel f. Moreover, even an institution (or portion of an institution) that is not certified for Medicare can serve to prolong an inpatients benefit period if it meets either the basic hospital or SNF definition discussed above.   10.4.3.1 - Hospital Stay and End of Benefit Period  (Rev. 1, 09- 11-02)  In order to end a benefit period, for at least 60 consecutive days, a beneficiary cannot have been in a hospital which meets the initial requirement in the definitions in Chapter 5, 20.1 through 20.7 of this publication.  That is, the beneficiary cannot have been in a facility that is primarily engaged in providing, by or under the supervision of a physician(s), to inpatients:    Diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons or rehabilitation services for injured, disabled, or sick persons; or    Psychiatric services for the diagnosis and treatment of mentally ill persons.  A stay in a hospital outside the United States prolongs a benefit period. It may be assumed, in the absence of evidence to the contrary, that:    A foreign hospital in which a beneficiary spent one or more days meets the requirement of the definition in Chapter 5, 20 of this manual; and    The beneficiary's statement about length and place of stay is correct.   10.4.3.2 - SNF Stay and End of Benefit Period  (Rev.10880, Issued: 08- 06-21, Effective: 11 -08- 21, Implementation: 11- 08-21  Similarly, to end a benefit period, a beneficiary cannot have been an inpatient (see 10.4.4) of a SNF for at least 60 consecutive days; where SNF is defined in accordance with 1861(a)(2) and 1819(a)(1) of the Social Security Act  as a facility which is primarily engaged in providing skilled nursing care and related services to residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.  As indicated above in 10.4.3, all Medicare -certified SNFs (including Medicare -certified distinct part SNFs) are automatically considered to meet this basic SNF definition by reason of the Medicare certification itself.  See 2166 of the State Operations Manual (Pub. 100- 07), Chapter 2, for the administrative criteria used in determining whether the basic SNF definition is met by a nursing home that is not Medicare- certified (including the noncertified portion of an institution that also contains a Medicare- certified distinct part SNF).   Examples: An individual may be discharged from and readmitted to a hospital or SNF several times during a benefit period and still be in the same benefit period if 60 consecutive days have not elapsed between discharge and readmission.  The stays need not be for related physical or mental conditions.  Example 1: X was born 8/9/1936. On 7/28/2001, X entered a participating general hospital. After he/she had been in the hospital for 2 weeks, X was discharged on 8/11/2001.  On his/her doctors orders, X entered a participating SNF on 8/15/2001, and remained an inpatient there (see 10.4.4) until his/her discharge on 10/27/2001.  He/she had no further inpatient stays in 2001.  Xs benefit period began on 8/1/2001, the first day of the month he/she attained age 65 and was entitled to hospital insurance.  The benefit period ended 12/25/2001, the end of the 60- day period beginning with the date of his/her last discharge.   Example 2: Y, over age 65, entered a participating general hospital on 8/28/2000 for treatment of a heart condition.  He/she was discharged on 9/11/2000.  On 10/3/2000, Y entered a Medicaid -only nursing facility, and remained an inpatient of this facility (see 10.4.4) until his/her discharge on 11/17/2000. On 12/26/2000, Y was again admitted to a participating hospital because of injuries suffered in an accident.  He/she was discharged on 1/13/2001 and had no further inpatient stays in 2001.  Ys benefit period began on 8/28/2000.  His/her stay in the nursing facility began less than 60 days after his/her hospital stay and the benefit period was continued because he/she remained an inpatient there (see 10.4.4) even though Medicare did not cove r the stay.  The subsequent hospital stay began less than 60 days after the nursing facility stay and continued the benefit period although the condition treated was unrelated to his/her prior stays.  The benefit period ended on 3/14/2001, the end of the 60- day period beginning with the day of last discharge.   Example 3: Z, over age 65 and entitled to hospital insurance benefits, was admitted to General Hospital on 8/l/2000 and discharged on 8/10/2000, having received nonemergency hospital services.  General Hospital met all the requirements in the definition of  a hospital except those concerning utilization review and health and safety.  While General Hospital met the minimum requirements of an emergency hospital, Zs benefit period did not begin with his/her admission to this hospital because:   1. The hospital did not meet all of the requirements in the definition of a hospital; and   2. Although the hospital satisfied the minimum requirements for coverage of emergency services, Z did not receive emergency inpatient care there.   (As noted previously, a stay in an emergency hospital does not begin a benefit period unless it actually involves the receipt of covered inpatient emergency services; by contrast, even a nonemergency stay in such a hospital can serve as a qualifying hospit al stay for purposes of coverage under the posthospital extended care benefit.)  Z was admitted to Haven Convalescent Home on 8/20/2000 and remained an inpatient of the home (see 10.4.4) until his/her discharge on 3/1/2001.  He/she had no further inpatient stays in 2001.  Haven Convalescent Home became a participating SNF on 1/1/2001.  Z's benefit period began 1/1/2001, the day Haven Convalescent Home was determined to be a qualified SNF.  The services Z received from that date through discharge were extended care services even though they were not covered and, therefore, not charged against Zs Medicare SNF utilization.  (The services were not covered posthospital extended care services because Z was not admitted to a participating SNF within 30 days after discharge from the hospital.)  Zs benefit period ended 4/29/2001, the end of the 60-day period beginning with the date of his discharge from the convalescent home.  10.4.4 - Definition of Inpatient for Ending a Benefit Period  (Rev. 80, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  Generally, a beneficiary is an inpatient of a hospital if the beneficiary is receiving inpatient services in the hospital (i.e., not on an outpatient basis).  The type of care actually received is not relevant.