General

30.1 - General (Rev. 1, 10-01-03) A3-3106.2.A, HO-219.2.A An election not to use lifetime reserve days may be made by the beneficiary (or by someone acting on his or her behalf) at the time of admission to a hospital or at any time thereafter, subject to the limitations on retroactive elections described in §30.3 below. Hospitals are required to notify patients who have already used or will use 90 days of benefits in a benefit period that they can elect not to use their reserve days for all or part of a stay. The hospital notice should be given when the beneficiary has five regular coinsurance days left and is expected to be hospitalized beyond that period. Where the hospital discovers the patient has fewer than five regular coinsurance days left, it should immediately notify the patient of this option. The hospital should annotate its records at the time that it informed the patient of this option. In addition, it should make available an appropriate election statement or form to be included in the patient's hospital record if the patient elects not to use reserve days. (See §40.1 for sample election format). If a patient elects not to use reserve days, covered Part B services are billed on Form CMS-1450 or the electronic equivalent to the A/B MAC (A). A Medicare beneficiary who is eligible for medical assistance (Medicaid) under a State plan should be advised that such assistance would not be available if the beneficiary elects not to use the lifetime reserve days. However, this restriction on medical assistance payments does not apply to cases where the beneficiary is deemed to have elected not to use lifetime reserve days. In the following situations a beneficiary will be deemed to have elected not to use lifetime reserve days: 1. The average daily charge for covered services furnished during a lifetime reserve billing period is equal to or less than the coinsurance amount for lifetime reserve days; and • The hospital is reimbursed on a cost reimbursement basis; or • The hospital is reimbursed under the prospective payment system and lifetime reserve days are needed to pay for all or part of the outlier days. (See §§10.2 and 30.4.2.) 2. For the nonoutlier portion of a stay in a hospital reimbursed under the prospective payment system (acute hospital PPS, inpatient rehabilitation facility (IRF) PPS and a normal stay under long term care hospital (LTCH) PPS), if the beneficiary has one or more regular (nonlifetime reserve) days remaining in the benefit period upon admission to the hospital. (See §30.4.2.) Note the exception to this rule is the short stay outlier policy under LTCH PPS. 3. The beneficiary has no regular days available at the time of admission to a hospital reimbursed under the prospective payment system and the total charges for which the beneficiary would be liable if lifetime reserve days are not used is equal to or less than the charges for which the beneficiary would be liable if he or she used lifetime reserve days, i.e., the sum of the coinsurance amounts for the lifetime reserve days that would be used plus the total charges for outlier days, if any, for which no lifetime reserve days would be available because lifetime reserve days are exhausted. (See §30.4.2.) EXCEPTION: Even though a beneficiary would otherwise be deemed to have elected not to use lifetime reserve days, he or she will not be so deemed where benefits are available from another third party payer to pay some or all of the charges and the third party requires as a condition for payment that lifetime reserve days be used. In such cases, lifetime reserve days will be used unless the beneficiary specifically elects not to use them.