Determining Days Available

40 - Determining Days Available (Rev. 1, 10-01-03) A3-3104.5, HO-217.5, 42 CFR 409.63 Since payment can be made only for the number of days remaining after the reduction is applied, the following steps should be taken to determine the number of days available in the first benefit period for which payment can be made for inpatient psychiatric hospital services and inpatient services in a general hospital for the treatment of mental illness: 1. Determine how many days in the 150-day pre-entitlement period the patient spent in a psychiatric hospital; 2. Subtract these from 150. Payment is made for the remaining days in the following order of priority: 1. The 60 full benefit days; 2. The 30 regular coinsurance days; 3. The 60 lifetime reserve coinsurance days. Benefit days not available to the patient because of the psychiatric reduction (including lifetime reserve days) nevertheless, remain available for use in hospitalization not subject to the reduction; i.e., a general hospital stay for a nonpsychiatric condition. The lifetime days not previously used also remain available for any inpatient stays (including psychiatric hospital stays) in subsequent benefit periods. EXAMPLE l: The patient was an inpatient of a participating psychiatric hospital on his first day of entitlement. He had been in such a hospital in the pre-entitlement period for 20 days. Therefore, 130 days are payable. Payment would be made in the following order: 60 full benefit days, 30 coinsurance (61st thru 90th) days, then 40 coinsurance (lifetime) days. EXAMPLE 2: During the 150-day period preceding Medicare entitlement, an individual had been a patient of a general hospital for 60 days of inpatient psychiatric care and had spent 90 days in a psychiatric hospital, ending with the first day of entitlement. During the initial benefit period, the beneficiary spent 90 days in a general hospital and received psychiatric care there. The 60 days spent in the general hospital for psychiatric treatment before entitlement does not reduce the benefits available in the first benefit period. Only the 90 days spent in the psychiatric hospital before entitlement reduce such benefits, leaving a total of 60 available psychiatric days. However, after entitlement, the reduction applies not only to days spent in a psychiatric hospital, but also to days of psychiatric treatment in a general hospital. Thus, Medicare payment could be made only for 60 of the 90 days spent in the general hospital. EXAMPLE 3: An individual was admitted to a general hospital for a mental condition and, after 10 days, transferred to a participating psychiatric hospital. The individual remained in the psychiatric hospital for 78 days before becoming entitled to hospital insurance benefits and for 130 days after entitlement. The beneficiary was then transferred to a general hospital and received treatment of a medical condition for 20 days. The 10 days spent in the general hospital during the 150-day preentitlement period have no effect on the inpatient hospital benefit days available to the individual for psychiatric care in the first benefit period, even though the general hospital stay was for a mental condition. Only the 78 days spent in the psychiatric hospital during the pre-entitlement period are subtracted from the 150 benefit days. Accordingly, the individual has 72 days of psychiatric care (150 days less 78 days) available in the first benefit period. Benefits could be paid for the individual's hospitalization during the first benefit period in the following manner. For the 130-day psychiatric hospital stay, 72 days (60 full benefit days and 12 coinsurance days), and for the general hospital stay, 20 days (18 coinsurance and 2 lifetime reserve days).