Many of
us involved with lending a hand to older loved ones are
not yet on Medicare ourselves and haven't had a chance
to experience it's complexity first hand. Medicare isn't
the easiest program in the world to learn on the fly.
Even people over 65 who've been part of
it for a while sometimes come up against a wall of
confusion. Every now and then we'll try to sort through
some of the more confusing parts. Today it's Hospital
Benefit Periods.
If you
have medical insurance (non-Medicare) you're probably
used to having an annual deductible. The annual
deductible is the amount you must pay privately
out-of-pocket every year before your insurance begins to
pay. When you use your insurance you probably also make a
co-payment whenever you see the doctor, fill a
prescription, or use the hospital.
Your
annual deductible is owed anew at the beginning of each
year.
Medicare is the same, yet different, because it's
divided into two parts (not counting the new Part D for
prescriptions).
Part B
covers doctors, laboratories, clinics, etc. The annual
deductible, which re-starts every January, is $124 per
year ($124 in 2006 - it changes every year). Period. At the
first of the year, the insured, or the insured's
Medicare secondary insurer, must pay the first $124 of
all covered costs before Medicare begins coverage. The
insured, or the insured's secondary MediGap policy, will
then pay a 20% co-pay for all covered services. This is
fairly straightforward.
Part A
covers hospitals and care received as an inpatient
in a hospital. Part A also has a deductible ($952 in
2006), which the patient (or secondary insurer) must pay
before Medicare hospital coverage begins. However, this
deductible is not an annual deductible, it is a "Per
Benefit Period" deductible.
This is
where it gets tricky.
A
benefit period starts on the day you go into a hospital
or a skilled nursing facility. It ends after you have
not received any hospital or skilled nursing care for 60
days.
Example: You spend 5 days in the hospital. You then
return home. When you have been out of the hospital for
60 days your benefit period ends - 65 days after you
entered the hospital. If you then return to the
hospital, you or your secondary insurer owe another $952
deductible because you are in a new benefit period.
Example: You spend 5 days in the hospital. You then
enter a skilled nursing facility for 20 days of
rehabilitation. You then return home. Your benefit
period will end when you have been out of the skilled
nursing facility for 60 days - 75 days after you first
entered the hospital. If you then re-enter the hospital
another $952 will be due.
Example: You have returned home after being in the
hospital, or in a combination of hospital and skilled
nursing facility. After two weeks at home you must
return to the hospital. You have not been out of care
for 60 days, so you are still in your first benefit
period. You do not owe another $952. Medicare will pick
up where it left off.
There
are no limits to the number of Benefit Periods a
Medicare recipient may have. As long as the patient has
been out of hospital or skilled nursing care for at
least 60 days, a new benefit period is available.
So, if
you are medically unlucky, you could have as many as 5
benefit periods in a year. This would cost you at least
$4,760 in 2006 Benefit Period deductibles if you do not
have a Medicare secondary (MediGap) policy. This is why
these policies are so important.
So, you
say, the secret is to just go back to the hospital
inside the 60 day window. Medicare thought of that, and
made sure that the economics of staying in the hospital
would be even worse.
More on
that next time.
Here's a related article
