(Medicare General Information, Eligibility, and Entitlement)

Medicare General Information, Eligibility, and Entitlement  Chapter 3 - Deductibles, Coinsurance Amounts, and Payment Limitations   Table of Contents  (Rev. 12307, Issued:  10-19-23)  Transmittals for Chapter 3   10 - Hospital Insurance (Part A)  10.1 -  Inpatient Hospital Deductible  10.2 -  Coinsurance  10.2.1 -  Inpatient Services  10.2.2 -  Durable Medical Equipment (DME) Furnished as a Home Health Benefit  10.3 -  Basis for Determining the Part A Coinsurance Amounts  10.4 -  Benefit Period (Spell of Illness)  10.4.1 -  Starting a Benefit Period  10.4.2 -  Ending a Benefit Period 10.4.3 -  Definition of Hospital or SNF for Ending a Benefit Period  10.4.3.1 -  Hospital Stay and End of Benefit Period  10.4.3.2 -  SNF Stay and End of Benefit Period  10.4.4 -  Definition of Inpatient for Ending a Benefit Period 20 - Supplementary Medical Insurance (SMI) (Part B)  20.1 -  Supplementary Medical Insurance Incurred Expenses  20.2 -  Part B Annual Deductible  20.3 -  Part B Coinsurance  20.4 -  Exceptions to Annual Deductible and Coinsurance  20.4.1 -  Applications of Deductible and Coinsurance in Liability and Indemnification Situations  20.5 -  Blood Deductibles (Part A and Part B)  20.5.1 -  Part A Blood Deductible  20.5.2 -  Part B Blood Deductible  20.5.3 -  Items Subject to Blood Deductibles  20.5.4 -  Obligations of the Beneficiary to Pay for or Replace Deductible Blood 20.5.4.1 -  Replacement of Blood  20.6 -  Part B Premium 30 - Outpatient Mental Health Treatment Limitation  40 - Limitation on Physical Therapy, Occupational Therapy and Speech -Language Pathology Services  10 - Hospital Insurance (Part A)   10.1 - Inpatient Hospital Deductible  (Rev. 1, 09- 11-02)  The patient is responsible for a deductible amount for inpatient hospital services in each benefit period.  For each year after 1991, the Secretary of the Department of Health and Human Services (DHHS) is required to set the deductible and coinsurance amounts between September 1 and September 15 of the preceding year.  The deductible will be set at an amount equal to the deductible for the preceding year, changed by the same percentage as applies to PPS payment rates, and adjusted to reflect changes in real  case mix.  The deductible and coinsurance amounts are shown in the chart in 10.3 of this chapter.   The coinsurance amount is based on the deductible applicable for the calendar year in which the coinsurance days occur.  The deductible is satisfied only by charges for covered Part A services.  Expenses for covered services count toward the deductible on an incurred, rather than paid, basis.  Expenses incurred in one benefit period cannot be applied toward the deductible in a later benefit period.  Expenses incurred in meeting the blood deductible do not count toward the inpatient hospital deductible.  A reduction in benefit days resulting from confinement in a psychiatric hospital, on and immediately preceding the date of entitlement, does not affect the amount of the deductible for which the patient is responsible.   If the actual charge is less than the deductible and the customary charge, the customary charge is applied to the deductible.   A beneficiary is not responsible for payment of the deductible for an inpatient stay if the provider has been determined to be liable because the care was not medically necessary or because the care provided was custodial.  10.2 - Coinsurance  (Rev. 1, 09- 11-02)  The following subsections describe coinsurance.   10.2.1 - Inpatient Services  (Rev. 1, 09- 11-02)  In each benefit period, the patient is responsible for coinsurance amounts equal to:    One-fourth of the inpatient hospital deductible for each day of inpatient hospital services from the 61st through the 90th days;    One-half of the inpatient hospital deductible for each lifetime reserve day (the 91st through the 150th days of inpatient hospital services); and    One-eighth of the inpatient hospital deductible for each day of extended care services from the 21st through the 100th days.  A beneficiary is not responsible for payment of the coinsurance for a stay if the provider has been determined to be liable becaus e the care was not medically necessary or because the care provided was custodial.   Use the chart in 10.3 of this chapter to determine the applicable coinsurance amounts.  Where the actual charge to the patient for the 61st through the 90th days of inpatient hospital services is less than the applicable coinsurance amount, the coinsurance is the actual charge per day.  Where the actual charge to the patient for lifetime rese rve days is less than the coinsurance amount for those days, the beneficiary may be deemed to have elected not to use the days because he/she would not benefit from their utilization.   10.2.2 - Durable Medical Equipment (DME) Furnished as a Home Health Benefit  (Rev. 1, 09- 11-02)  The patient is responsible for 20 percent of the payment amount for DME furnished as a home health benefit.   10.3 - Basis for Determining the Part A Coinsurance Amounts  (Rev.12307; Issued: 10- 19-23; Effective: 01 -01-24; Implementation: 01- 02-24)  The applicable inpatient deductible is the one in effect during the calendar year in which the patient's benefit period begins (i.e., in most cases, the year in which the first inpatient hospital services are furnished in the benefit period). Except for 1989, the coinsurance amount is based on the deductible applicable for the calendar year in which the coinsurance days occur.   When Deductible and/or Coinsurance Are Applicable for Part A   Inpatient Hospital - First 60 Days  Deductible applicable equal to national average cost per day Inpatient Hospital - 61st thru 90th Day  Coinsurance per day always equal to 1/4 of inpatient hospital deductible  Inpatient Hospital - 60 Lifetime Reserve Days (nonrenewable) - 91st thru 150th day Coinsurance always equal to 1/2 of inpatient hospital deductible  Skilled Nursing Facility 21st thru 100th Day  Coinsurance always equal to 1/8 of inpatient hospital deductible  Home Health Agency  No Deductible No Coinsurance (except for 20 percent coinsurance for DME and prosthetics/ orthotics)  Blood  1st 3 pints (or equivalent units of packed red blood cells) in a calendar year - combined Part A and B  Hospice *  a. Drugs and Biologicals  b. Respite  Care  a. 5 percent of the cost determined by the drug copayment schedule (may not exceed $5 per  prescription)  b. 5 percent of the payment for a respite care  day  *Hospices may charge coinsurance for two services only, drugs and biologicals, and respite care. The amount of coinsurance for each prescription may not exceed $5.00. The amount for respite care may not exceed the inpatient deductible for the year in which  the hospital coinsurance period began.   Deductible and Coinsurance Amounts  Year  Part A  Deductible,  1st 60 Days  Part A  Coinsurance,  61st- 90th Days  Part A Coinsurance,  60 Lifetime Reserve Days  Part A  SNF Coinsurance  21st- 100th Days  1986  $492  123 246 61.50  1987  520 130 260 65.00  1988  540 135 270 67.50  1989  560 0 (1)  0 (1)  0(2) 1990  592 148 296 74.00  1991  628 157 314 78.50  1992  652 163 326 81.50  1993  676 169 338 84.50  1. Coinsurance was not charged for inpatient hospital care in CY 1989 due to Catastrophic Coverage. The deductible was  applied.  2. Under Catastrophic Coverage, a coinsurance payment of $25.50 was due for days 1- 8 of SNF care. No SNF coinsurance was due after day 8 in  1989.   10.4 - Benefit Period (Spell of Illness)  (Rev. 1, 09- 11-02)  A benefit period is a period of time  for measuring the use of hospital insurance benefits.  It is a period of consecutive days during which covered services furnished to a patient, up to certain specified maximum amounts, may be paid for by the hospital insurance plan.  For example, a patien t is eligible for 90 days of hospital care in a benefit period and 100 days of extended care services during the same benefit period.  A patient may be eligible for as many as l50 days of hospital care in a benefit period if he/she draws on his/her lifetime reserve.  As long as a person continues to be entitled to hospital insurance, there is no limit on the number of benefit periods he/she may have.  The term "benefit period" 1994  696 174 348 87.00  1995  716 179 358 89.50  1996  736 184 368 92.00  1997  760 190 380 92.00  1998  764 191 382 95.50  1999  768 192 384 96.00  2000  776 194 388 97.00  2001  792 198 396 99.00  2002  812 203 406 101.50  2003  840 210 420 105.00  2004  876 219 438 109.50  2005  912 228 456 114.00  2006  952 238 476 119.00  2007  992 248 496 124.00  2008  1,024  256 512 128.00  2009  1,068  267 534 133.50  2010  1,100  275 550 137.50  2011  1,132  283 566 141.50  2012  1,156  289 578 144.50  2013  1,184  296 592 148.00  2014  1,216  304 608 152.00  2015  1,260  315 630 157.50  2016  1,288  322 644 161.00  2017  1,316  329 658 164.50  2018  1,340  335 670 167.50  2019  1,364 341 682 170.50  2020  1,408  352 704 176.00   2021  1,484  371 742 185.50  2022  1,556  389 778 194.50  2023  1,600  400 800 200.00  2024  1,632  408 816 204.00  is synonymous with spell of illness.  Since the term "spell of illness" could connote a single illness or a particular "spell" of sickness, the term benefit period is used in communications with the public.  10.4.1 - Starting a Benefit Period  (Rev. 80, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  A benefit period begins with the first day (not included in a previous benefit period) on which a patient is furnished inpatient hospital or extended care services by a qualified provider in a month for which the patient is entitled to hospital insurance b enefits.