(Medicare General Information, Eligibility, and Entitlement)

10.4.4 - Definition of Inpatient for Ending a Benefit Period  (Rev. 80, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  Generally, a beneficiary is an inpatient of a hospital if the beneficiary is receiving inpatient services in the hospital (i.e., not on an outpatient basis).  The type of care actually received is not relevant.   However, a different definition of inpatient applies in determining the end of a benefit period for a beneficiary in a SNF, under which such a beneficiary is considered an inpatient in this context only if the beneficiary's care in the SNF meets certain skilled level of care standards.  Specifically, the beneficiary must need and receive a skilled level of care while in the SNF.   This means that in order to have been an inpatient for benefit period purposes while in a SNF, the beneficiary must have required and received skilled services on a daily basis which could, as a practical matter, only have been provided in a SNF on an inpatient basis.  (Under the regulations at 42 CFR 409.60(b)(2), an additional level of care criterion at 42 CFR 409.31(b)(2) --requiring that the SNF care must in some way relate back to a condition that was present during the beneficiarys qualifying hospital stay--does not apply to benefit period determinations.)  If these provisions were not met during the prior SNF stay, the beneficiary was not an inpatient of the SNF for purposes of prolonging the benefit period.  Conversely, a beneficiary would remain an SNF inpatient in this context (thus prolonging his or her current benefit period) for as long as the beneficiary continues receiving a skilled level of care in the SNF --even if Part A payment has ended due to the beneficiarys exhaustion of SNF benefits.  Use the following presumptions for determining whether the skilled level of care standards were met during a prior SNF stay.   Presumption 1: A beneficiary's care in a SNF met the skilled level of care standards if a Medicare SNF claim was paid for the care, unless such payment was made under limitation on liability rules.   Presumption 2: A beneficiary's care in a SNF met the skilled level of care standards if a SNF claim was paid for the services provided in the SNF under the special Medicare limitation on liability rules pursuant to placement in a non- certified bed.   Presumption 3: A beneficiary's care in a SNF did not meet the skilled level of care standards if a claim was paid for the services provided in the SNF pursuant to the general Medicare limitation on liability rules.  (This presumption does not apply to plac ement in a non- certified bed.  For claims paid under these special provisions, see Presumption 2.)   Presumption 4: A beneficiary's care in a Medicaid nursing facility (NF) did not meet the skilled level of care standards if a Medicaid claim for the services provided in the NF was denied on the grounds that the services received were not at the NF level of care (even if paid under applicable Medicaid administratively necessary days provisions which result in payment for care not meeting the NF level of care requirements).   Presumption 5: A beneficiary's care in a SNF met the skilled level of care standards if a Medicare SNF claim for the services provided in the SNF was denied on grounds other than that the services were not at the skilled level of care.   Presumption 6: A beneficiary's care in a SNF did not meet the skilled level of care standards if a Medicare claim for the services provided in the SNF was denied on the grounds that the services were not at the skilled level of care and no limitation of li ability payment was made.   Presumption 7: A beneficiary's care in a SNF did not meet the skilled level of care standards if no Medicare or Medicaid claim was submitted by the SNF.  Presumptions 1 through 4 cannot be rebutted.  Thus, prior Medicare and Medicaid claim determinations that necessarily required a level of care determination for the time period under consideration are binding for purposes of a later benefit period calculat ion.  Presumptions 5 through 7 can be rebutted by the beneficiary showing that the level of care needed or received is other than that which the presumption dictates.   Presumption 6 can be rebutted because the Medicare skilled level of care definition for coverage purposes is broader than the skilled level of care definition used here for benefit period determinations.  Specifically, the requirement referred to in Chapte r 4, 40.2 regarding prior hospital care related to the SNF care is included in the Medicare SNF coverage requirements but is not included in the standard for benefit period determinations.  Therefore, Medicare payment could have been denied for a SNF stay on level of care grounds (i.e., not even waiver payment was made) because of noncompliance with that requirement, even though skilled level of care requirements for benefit period determinations were in fact met by the SNF stay.  Consequently, when Medicare SNF pay ment is denied on level of care grounds, the beneficiary must be given the opportunity to demonstrate that he/she still needed and received a skilled level of care for purposes of benefit period determinations.   NOTE:   Effective October 1, 1990, the levels of care that were previously covered separately under the Medicaid SNF and intermediate care facility (ICF) benefits are combined in a single Medicaid nursing facility (NF) benefit.  Thus, the Medicaid NF benefit inc ludes essentially the same type of skilled care covered by Medicare's SNF benefit, but it includes less intensive care as well.  This means that when a person is found not to require at least a Medicaid NF level of care (as under Presumption 4), it can be presumed that he or she also does not meet the Medicare skilled level of care standards.  However, since the NF benefit can include care that is less intensive than Medicare SNF care, merely establishing that a person does require NF level care does not necessarily mean that he or she also meets the Medicare skilled level of care standards.  Determining whether an individual who requires NF level care also meets the Medicare skilled level of care standards requires an actual examination of the medical evidence and cannot be accomplished through the simple use of a presumption.  Therefore, the previous references to Medicaid claims have been deleted from those presumptions which establish that an individual does meet the Medicare standards.   Medicare no -payment bills submitted by a SNF result in Medicare program payment determinations (i.e., denials).  Therefore, such no- payment bills trigger the appropriate presumptions.  This also applies in any State where the Medicaid program utilizes no-payment bills which lead to Medicaid program payment determinations.  If a SNF erroneously fails to submit a Medicare claim (albeit a no -pay claim) when Medicare rules require such submission, A/B MACs (A) request a SNF to submit one.  Once the no- pay bill is submitted and denied, the applicable presumption (other than presumption 7) is triggered.  If a patient is moving from a SNF level of care to a non- SNF level of care i n a facility certified to provide SNF care, occurrence code 22 (date active care ended) is used to signify the beginning of the no- pay period on the bill and trigger the appropriate presumptions.  Where the presumptions are rebuttable (i.e., 5 through 7), rebuttal showings are permitted at both A/B MAC (A) determination levels under 42 CFR 405, Subpart G (i.e., a rebuttal showing regarding the status of a prior SNF stay is made at the time that an inpatient claim is submitted and/or at the reconsideration level).  A/B MACs (A) evaluate rebuttal documentation even if the presumption being rebutted was triggered by a Medicaid denial.   This special rule for determining whether a beneficiary in a SNF is an inpatient for benefit period purposes is applicable in all cases where a prior SNF stay affects benefit period status, not only when a beneficiary is in exhausted or copay status and is  seeking to renew a benefit period.  The rule has equal application where it results in the beneficiary starting a new benefit period and paying a new deductible without receiving an increase in the amount of Medicare benefits paid.   20 - Supplementary Medical Insurance (SMI) (Part B)  (Rev. 1, 09- 11-02)  Supplementary Medical Insurance is described in the following subsections.  20.1 - Supplementary Medical Insurance Incurred Expenses  (Rev. 1, 09- 11-02)  The SMI plan includes coverage for expenses incurred for the services described in Chapter 1, 10.3:   Payment may not be made under Part B for services furnished an individual entitled to have payment made for those services under Part A, e.g., if the expenses incurred were to satisfy a Part A deductible or coinsurance amount, or if payment would be made under Part A except for the lack of request for payment or physician certification.  20.2 - Part B Annual Deductible  (Rev. 12307; Issued: 10- 19-23; Effective: 01 -01-24; Implementation: 01- 02-24)  In each calendar year, a cash deductible must be satisfied before payment can be made under SMI. (See 20.4 of this chapter for exceptions.)   Calendar Year  Deductible  1966  1972  $50 1973  1981  $60 1982  1990  $75 1991  2004  $100  2005  $110  2006  $124  2007  $131  2008  $135  2009  $135  2010  $155  2011  $162  2012  $140  2013  $147  2014  $147  2015  $147  2016  $166  2017  $183  2018  $183  2019  $185  2020  $198  2021  $203  2022  $233  2023  $226  2024  $240   Expenses count toward the deductible on the basis of incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non- covered expenses do not count toward the deductible. Even though an individual is not entitled to Part B benefits for t he entire calendar year (i.e., insurance coverage begins after the first month of a year or the individual dies before the last month of the year), he or she is still subject to the full deductible for that year. Medical expenses incurred in the portion of  the year preceding entitlement to medical insurance are not credited toward the deductible.   The date of service generally determines when expenses were incurred, but expenses are allocated to the deductible in the order in which the bills are received. Services not subject to the deductible cannot be used to satisfy the deductible.   Pro Rata Amounts   Pro Rata Amounts   First Month  Second Month  2012  $100.20  $39.80  2013  $103.95  $43.05  2014  $114.99  $32.01  2015  $114.99  $32.01  2016  $118.86  $47.14  2017  $125.73  $57.27  2018   $126.88  $56.12  2019  $133.57  $51.43  2020  $140.46  $57.54  2021  $145.31  $57.69  2022  $150.66  $82.34  2023  $154.95  $71.05  2024  $161.71  $78.29   The Part B deductible is split into pro rata amounts. The purpose of the pro rata amount is to provide beneficiaries who are enrolled in managed care plans the benefit of assuming they have paid their deductible as if they were not enrolled in a managed care plan. The pro rata amount does not apply only to just the first tw o months of the year but rather for the number of months after first enrollment in a managed care plan that is necessary to cover the Part B deductible. Each year starts the deduction for the pro rata amount over again.   20.3 - Part B Coinsurance  (Rev. 1, 09- 11-02)  After the deductible has been satisfied, coinsurance of 20 percent is usually applicable.   For providers and suppliers that bill A/B MAC(A) or (HHH), the 20 percent may be based on the allowed amount, billed charges, or a preset rate per service (APC), depending upon the type of service.  See Claims Processing instructions for a description of coinsurance calculation for each benefit type.   Physicians and other suppliers will be paid 80 percent of allowed amount under the fee schedule amounts or in some instances reasonable charges incurred during the balance of the calendar year.  The patient is responsible for a coinsurance amount equal to 20 percent of the fee schedule amounts or reasonable charges for the items and services. (See 20.4 of this chapter for exceptions.)   20.4 - Exceptions to Annual Deductible and Coinsurance  (Rev. 11, Issued: 10- 22-04, Effective: 11 -22-04, Implementation: 11- 22-04)  There is no deductible for screening mammography effective for services January 1, 1998 and later.   Neither the annual deductible nor the 20 percent coinsurance apply with respect to: