Inpatient Psychiatric Benefit Days Reduction

10 - Inpatient Psychiatric Benefit Days Reduction (Rev. 1, 10-01-03) A3-3104, HO-217 If an individual is in a participating psychiatric hospital on the first day of the entitlement to hospital insurance, the number of inpatient benefit days in the first benefit period is subject to reduction. The days (not necessarily consecutive) on which an individual was an inpatient of a psychiatric hospital in the 150-day period immediately before the first day of entitlement must be subtracted from the 150 days of inpatient hospital services for which he/she would otherwise be eligible in the first benefit period. Days spent in a general hospital for diagnosis or treatment of a psychiatric condition prior to entitlement will not reduce the patient's 150 inpatient benefit days in the initial benefit period. After entitlement, the reduction applies not only to inpatient hospital services received in a psychiatric hospital, but also to services received in a general hospital if the individual is an inpatient of the general hospital primarily for the diagnosis or treatment of mental illness. If a patient has no psychiatric benefit days remaining because of the reduction, Medicare payment may still be made for up to 150 days of inpatient hospital services that are not for the diagnosis and treatment of mental illness. EXAMPLE l: John was admitted to a Medicare participating psychiatric hospital named Spring Psychiatric Hospital on January 20. John’s Medicare entitlement was effective February 1 while John was still an inpatient of Spring Psychiatric Hospital. The 12 days of inpatient psychiatric care prior to entitlement are deducted from the 150 days available in the first benefit period. John has 138 days available in the first benefit period (150 minus 12 = 138). EXAMPLE 2: Mary was admitted to Spring Psychiatric Hospital on January 2 and discharged January 31. She was readmitted March 1 and discharged April 15. Mary’s Medicare entitlement became effective April 1. Mary used a total of 60 psychiatric days in the 150 day period prior to her Medicare entitlement. Therefore, the days available to Mary in her first benefit period are 90 days. Pre-entitlement days used by Mary were 29 for her January admission and 31 used during her March admission prior to her entitlement April 1.