Benefit Period

Inpatient skilled care and services are covered for up to 100 days per benefit period. If a member’s coverage begins while in a SNF, any SNF days used in that benefit period prior to the member’s effective date will apply toward the 100-day benefit. If a member is a SNF inpatient, and needs to be admitted to an acute care hospital for an illness related to the original problem or a new diagnosis, the consecutive days will stop temporarily until the member is transferred back to the SNF.

If a member is discharged from a SNF and within 60 days requires readmission to the SNF, the member must use the existing benefit period.

It is important to note that a benefit period (spell of illness) cannot end while a beneficiary is an inpatient of a hospital, even if the hospital does not meet all necessary requirements for starting a benefit period. Similarly, a benefit period cannot end while a beneficiary is an inpatient of a SNF (meaning a new benefit period cannot be started) as defined below.

For a member to have a new benefit period.

To end a benefit period, a beneficiary cannot have been an inpatient of a hospital or a SNF for at least 60 consecutive days. SNF is defined as a facility that is primarily engaged in providing skilled nursing care and related services to residents who require medical or nursing care, or rehabilitation services of injured, disabled or sick persons.

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.

Updated 01/2020