(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 5 - Lifetime Reserve Days   Table of Contents  (Rev.  257, 03- 01-19)  Transmittals for Chapter 5   10 - Summary of Provision 10.1 -  Effect of Reserve Days on Guarantee of Payment Provision 10.2 -  Reserve Days Not Available Where Average Charges Do Not Exceed One-Half Inpatient Hospital Deductible  10.3 -  Availability of Reserve Days Where Psychiatric Limitations Are Involved  10.4 -  Availability of Reserve Days for Hospital Emergency Services  10.5 -  Physician Certification  20 - When Payment Will Be Made for Reserve Days  30 - Election Not to Use Lifetime Reserve Days  30.1 -  General  30.2 -  Election Made Prospectively  30.3 -  Retroactive Election  30.4 -  Period Covered by Election 30.4.1 -  Hospitals Not Reimbursed Under Prospective Payment System  30.4.2 -  Hospitals Reimbursed Under Prospective Payment System  30.4.2.1 -  Beneficiary Has One or More Regular Benefit Days Available at Time of Admission to PPS Hospital - Discharge Before October 1, 1997  30.4.2.2 -  Beneficiary Has No Regular Days Available at Time of Admission -  Discharge Before October 1, 1997  30.5 -  Election Where Beneficiary Is Incapacitated  30.6  Lifetime Reserve Days and Long Term Care Hospital (LTCH) Prospective Payment System (PPS)  40 - Content of Election  40.1 -  Election Format  40.2 -  Revocation of Election 40.2.1 -  Revocation Format  10 - Summary of Provision  (Rev. 1, 10- 01-03) A3-3106.A, HO -219.A   Each beneficiary has a lifetime reserve of 60 days of inpatient hospital services to draw upon after having used 90 days of inpatient hospital services in a benefit period.  Payment will be made for such additional days of hospital care after the 90 days of benefits have been exhausted unless the individual elects not to have such payment made (and thus saves the reserve days for a later time).   A coinsurance amount equal to one -half of th e inpatient hospital deductible applies to lifetime reserve days.   10.1 - Effect of Reserve Days on Guarantee of Payment Provision  (Rev. 1, 10- 01-03) A3-3106.B, HO -219.B, A3- 3714   The guarantee of payment provisions extend to inpatient services furnished to individuals who have exhausted their eligibility for inpatient hospital services and does not extend to individuals who have no coverage for other reasons, e.g., one who is not entitled under hospital insurance or whose entitlement has been terminated.   Under the guarantee of payment provisions a hospital may be paid, under certain conditions, for inpatient services furnished to a beneficiary whose eligibility for inpatient benefit days has been exhausted, including exhaustion of the 190- day lifetime limitation on inpatient psychiatric hospital services.  The guarantee of payment provisions are not applicable until the individual has exhausted 60 lifetime reserve days of inpatient hospital services except where the beneficiary is deemed to have elected no t to use lifetime reserve days.  (See 10.2, below, and see 30 , below.)   See the Medicare Claim Processing Manual, Chapter 2 for instructions relating to guarantee of payment.  10.2 - Reserve Days Not Available Where Aver age Charges Do Not Exceed One -Half Inpatient Hospital Deductible  (Rev. 1, 10- 01-03) A3-3106.C, HO -219.C   A beneficiary will be deemed to have elected not to use the lifetime reserve days where the average daily charge for covered services furnished during a lifetime reserve days billing period is equal to or less than the coinsurance amount for the lifetime reserve days.  Such days are treated as noncovered days rather than potential lifetime reserve days since the beneficiary would be required to pay for a ll of the hospital charges regardless of his or her election and therefore would not benefit from use of lifetime reserve days.  This rule applies to hospitals not paid under PPS.  See 30  for deemed election under PPS.  10.3 - Avai lability of Reserve Days Where Psychiatric Limitations Are Involved  (Rev. 1, 10- 01-03) A3-3106.D, HO -219.D   A beneficiary's reserve days are not available to the extent that he or she is subject to the 150-day psychiatric hospital reduction provision, i.e., where the beneficiary has been in a psychiatric hospital during the l50- day period immediately preceding the first day of entitlement to hospital insurance benefits and is still in a psychiatric hospital on the first day of entitlement.  (See the Medicar e Benefit Policy Manual, Chapter 4, 10.)  The reserve days are available, however, if such a beneficiary receives nonpsychiatric services in a general hospital or if the beneficiary starts a new benefit period.  The reserve days are also not available to a beneficiary who is in a psychiatric hospital after using l90 days of inpatient psychiatric hospital care during his or her lifetime.  (See the Medicare Benefit Policy Manual, Chapter 4, 50.)   10.4 - Availability of Reserve Days for Hospital Emergency Se rvices  (Rev. 1, 10- 01-03) A3-3106.E, HO -219.E   The reserve days are available for emergency services furnished in nonparticipating hospitals.  10.5 - Physician Certification  (Rev. 1, 10- 01-03)  A3-3106.F, HO -219.F   Physician certification requirements are applicable to lifetime reserve days.   20 - When Payment Will Be Made for Reserve Days  (Rev. 1, 10- 01-03)  A3-3106.1, HO -219.1  When a patient receives services after exhaustion of 90 days of coverage, benefits will be paid for available reserve days on the  basis of the patient's request for payment, unless the patient has indicated in writing that he or she elects not to have the program pay for such services.   30 - Election Not to Use Lifetime Reserve Days  (Rev. 1, 10- 01-03) A3-3106.2, HO -219.2  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 limita tions 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 reserv e 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 f orm 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 u se 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 h ave 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.   30.2 - Election Made Prospectively  (Rev. 1, 10- 01-03) A3-3106.2.B, HO -219.2.B   Ordinarily, an election not  to use reserve days will apply prospectively.  If the election is filed at the time of admission to a hospital, it may be made effective beginning with the first day of hospitalization or with any day thereafter.  If the election is filed later, it may be made effective beginning with any day after the day it is filed.   30.3 - Retroactive Election  (Rev. 1, 10- 01-03) A3-3106.2.C, HO -219.2.C   A beneficiary may retroactively elect not to use reserve days provided when:    The beneficiary (or some other source) offers to pay the hospital for any of the services not payable under Part B; and    The hospital agrees to accept the retroactive election.   In this case, the hospital will contact the A/B MAC (A) for procedures for correcting any claims already submitted.   A retroactive election not to use the lifetime reserve days must be filed within 90 days following the beneficiary's discharge from the hospital unless benefits are available from a third party payer to pay for the s ervices and the hospital agrees to the retroactive election.  In that case, the beneficiary may file an election not to use the lifetime reserve days later than 90 days following discharge.   EXAMPLE 1:   Prior to July 1, Mr. Jones had used 90 days of inpati ent hospital services in a benefit period.  Beginning July 1, he was hospitalized for 10 additional days in that same benefit period.  He was informed of his election right on July 1 at the time of admission and indicated that he wanted to use his reserve days for that stay.  One month after being discharged from the hospital, Mr. Jones informed the hospital's billing office that he now wished to save his reserve days for a future stay.  Mr. Jones agreed to pay the hospital for the services he received duri ng the 10 days of hospitalization, which were not payable under Part B, and was permitted to file a retroactive election not to use his reserve days, effective July 1.   EXAMPLE 2:   On July 1, Mrs. Smith was discharged from a hospital after being hospitaliz ed for 105 days.  The hospital billed Medicare for 90 regular days plus 15 lifetime reserve days.  On October 20 (more than 90 days following discharge), Mrs. Smith learned that a private insurer could pay for the last 15 days of the stay.  She informed the hospital that she wished to file a retroactive election not to use lifetime reserve days for the last 15 days of the stay.  The hospital agreed to the request, and Mrs. Smith filed an election form.  The hospital refunded the Medicare payment and billed the private insurer instead.