Inpatient Days Counting Toward Benefit Maximums

30 - Inpatient Days Counting Toward Benefit Maximums (Rev. 1, 10-01-03) A3-3107, A3-3136, HO-216.5, SNF-244 A. 90-Day Benefit Limitation Inpatient hospital (including psychiatric hospital) services count toward the maximum of 90 benefit days payable per benefit period only if: • Payment for the services is made; • Payment for the services would be made if a request for payment and claim were filed properly and timely, a physician certified that the services were necessary, if required, and the provider submitted all necessary evidence; or • Payment cannot be made because the inpatient deductible or coinsurance is higher then the charges. B. Lifetime Reserve Days Part A benefits allow for 60 lifetime reserve days for use after a 90-day benefit period has exhausted. The 60 days are not renewable and may be used only once during a beneficiary’s lifetime. Inpatient hospital services count toward the maximum of 60 lifetime reserve days under the same conditions as in subsection A except that days are not counted if: • The individual elects not to have payment made (See the Medicare Benefit Policy Manual, Chapter 5, Lifetime Reserve Days, §30), or • The coinsurance rate exceeds the daily charge. (See the Medicare Benefit Policy Manual, Chapter 5, Lifetime Reserve Days, §10.2). C. Lifetime Inpatient Psychiatric Hospital Limitation Inpatient psychiatric hospital services count toward the 190-day lifetime limitation on inpatient psychiatric hospital services only if the conditions in subsection A are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital (or distinct part). D. Inpatient Post-hospital Extended Care Services Counting Toward Maximums Post-hospital extended care services count toward the maximum number of benefit days payable per benefit period only if: • Payment for the services is made, or • Payment for the services would be made if a request for payment were properly filed, the physician certified that the services were medically necessary, and the provider submitted all necessary evidence. When payment cannot be made because of the extended care coinsurance requirement, the day(s) used nevertheless count toward the beneficiary's maximum days of extended care.