Citations:

Social Security Act—Sec. 1861(o)

A. Definition

A benefit period (spell of illness) is the time period used in the hospital insurance program in determining whether covered Part A services can be paid for by the program. The number of days that inpatient hospital and extended care services are provided a beneficiary is related to the benefit period, as is the number of home health visits prior to July 1, 1981. Although the days for which the program will make payment are limited by the benefit period, a beneficiary is not limited in the number of benefit periods he may have. Effective July 1, 1981, the spell of illness requirements for home health services are eliminated.

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 days have not elapsed between discharge and readmission. The stay need not be for related physicial or mental conditions.

B. Beginning a benefit period

A benefit period is a period of consecutive days that begins with the first day (not included in a previous spell of illness) on which a beneficiary is furnished inpatient hospital or extended care services by a qualified provider. THUS, GENERALLY, THE BENEFIT PERIOD BEGINS WHEN COVERED INPATIENT SERVICES ARE INITIALLY FURNISHED TO AN ENTITLED INDIVIDUAL.

A spell of illness may also begin with a stay in a qualified “emergency hospital” in Canada or Mexico when it furnishes the patient covered emergency inpatient hospital services or when it is more accessible for a border resident including nonemergency situations.

If a person is in a nonqualified institution and is subsequently transferred to a qualified hospital (general, psychiatric, or tuberculosis), his spell of illness begins on admission to the qualified hospital (HI 00401.225).

Admission to a qualified SNF begins a benefit period even though payment for the services cannot be made under Part A because the prior hospitalization or transfer requirement has not been met.

For coverage of home health services only, prior to July 1, 1981, a benefit period begins when a beneficiary is admitted to a nonparticipating hospital that has Joint Commission on Accreditation of Hospital (JCAH) certification, or that of the American Osteopathic Association (AOA). This rule applies whether the hospital is within the United States or in a foreign country or whether the services are emergency or non-emergency.

C. Continuing a benefit period

It is important to note that for purposes of continuing a benefit period the hospital or SNF in which the stay occurs need not meet all of the requirements that are necessary for starting a benefit period.

Inpatient services will prolong the beneficiary's benefit period if the hospital is primarily engaged in providing, by or under the supervision of physician(s), to inpatients:

1. diagnostic and therapeutic services for medical diagnosis, treatment, and care of, or rehabilitation services to injured, disabled, or sick persons; or

2. psychiatric services for the diagnosis and treatment of mentally ill persons; or

3. medical services for the diagnosis and treatment of tuberculosis.

Participating hospitals will always meet this requirement. For nonparticipating hospitals see the Directory of Medical Facilities.

A stay in a hospital outside the United States prolongs a spell of illness. It may be assumed, in the absence of contrary evidence, that a foreign hospital in which a beneficiary spent one or more days meets one of the above requirements and that the beneficiary's statement about length and place of stay is correct.

Similarly, inpatient services in a SNF or nonparticipating nursing facility prolong a beneficiary's benefit period if the facility meets at least the requirement that it is primarily engaged in providing to inpatients skilled nursing care and related services for patients who require medical or nursing care, or rehabilitation services for injured, disabled, or sick persons. Participating SNF's always meet this definition. For nonparticipating facilities see the Directory of Medical Facilities.

D. Ending a benefit period

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 nursing facility. To determine the 60 consecutive day period, begin counting with the day on which the individual was discharged.