(Medicare Benefit Policy Manual)

If a beneficiary is physically or mentally unable to file an election not to use reserve days, certain other individuals may file the election on the beneficiary's behalf:   1. If the charges will be paid by other hospital insurance or if some other person agrees to pay the hospital for the services, an election not to use reserve days may be filed by any of the individuals who may sign a Request for Payment on behalf of the beneficiary (e.g. , relative, legal guardian).   2. If an incapacitated beneficiary does not have other hospital insurance, and no other person agrees to pay the hospital for the services, only the beneficiarys legal representative may file an election on the beneficiary's beh alf.  30.6  Lifetime Reserve Days and Long Term Care Hospital (LTCH) Prospective Payment System (PPS)  (Rev. 1, 10- 01-03)   When a Long Term Care Hospital inpatient stay triggers a full LTC -DRG payment (i.e., it exceeds the short -stay outlier threshold), Medicares payment is for the entire stay up to the high cost outlier threshold, regardless of patient coverage.  But for lengths of stay equal to or below 5/6  of the average length of stay for a specific LTC -DRG, Medicares payment is only for covered day s.  For a LTC -DRG where the ALOS is 30, 25 days (5/6 of 30) would be the short -stay outlier threshold.  If a patients stay is 25 days or less, Medicare will pay it as a short- stay outlier.  So, if for example, a patient has only 15 remaining days of Medic are coverage and stays 24 days in the LTCH, Medicare will only pay for 15 days (under the short -stay policy).  If the patient has 27 days remaining of Medicare coverage and stays for 26 days, Medicare would pay a full LTCDRG.   In this scenario, the patient s length of stay exceeded the short stay outlier threshold and the patient also had sufficient Medicare covered days to generate a full LTC -DRG payment, which would constitute Medicare payment until and unless the stay had become a high cost outlier.  Once the beneficiary exceeds the 5/6  short -stay outlier threshold and receives the full LTC -DRG payment, consistent with IPPS, the remaining days of the stay (and associated charges) are considered covered until the high cost outlier is reached even though the beneficiary may have already reached the 90 th regular Medicare covered day within the benefit period.  Once the beneficiary reaches the high cost outlier threshold, the beneficiary may choose to use the lifetime reserve days.  The beneficiary has no coinsurance (or any other) liability for the gap between the 90th  day and the start of lifetime reserve days.   Policy regarding the use of lifetime reserve days is the same as under the IPPS.  In the case of a stay that is categorized as a short -stay outlier for payment purposes (because the patient has run out of regular benefit days prior to exceeding the short -stay outlier threshold of 5/6 of the ALOS for the specific LTC -DRG), the remaining days of the patients stay will be counted against the beneficiary s lifetime reserve days (in the absence of an election not to use them) for the remainder of the episode of care, that is, until either the patient is discharged or the life -time reserve days are exhausted.  Once a beneficiary starts using lifetime reserv e days, each remaining day of hospitalization for that episode of care will be counted against those reserve days, even if no additional Medicare payments are generated until the high cost outlier threshold is reached.   Consistent with the policy under IPPS, Medicare will pay for high cost outlier payments only for covered days, that is, days for which the beneficiary has either regular benefit days or life -time reserve days for the period (or portion) of the stay beyond the high cost outlier threshold, for example:   EXAMPLE 7:   Mr. Kidd is admitted to the LTCH with 26 remaining days of regular Medicare coverage and is grouped to a LTC -DRG with an ALOS of 30 days.  On the 26th  day of that stay, Mr. Kidd has sufficient regular benefit days to trigger a ful l LTC -DRG payment (greater than 5/6  of the ALOS for that LTC -DRG) for this stay without going into lifetime reserve days.  Mr. Kidd would only need to consider using lifetime reserve days should the stay continue and ultimately become a high cost outlier.  EXAMPLE 8:   Mr. Adams  is grouped to the same LTC -DRG as Mr. Kidd but has only 10 remaining days of regular Medicare coverage.  Lifetime reserve days will be used for the entire remainder of the stay (unless Mr. Adams elects not to use them and to otherwis e assume responsibility for payments as a private pay patient) and the day count will continue, uninterrupted, until the patient is either discharged or the days are exhausted.  40 - Content of Election  (Rev. 1, 10- 01-03)  A3-3106.3, HO -219.3  A beneficiar y's election not to use reserve days should specify the name of the hospital and the starting date of the election.   Where the hospital is not reimbursed under the prospective payment system, the starting date of the election may be any day after regular benefits are exhausted.  Where the hospital is reimbursed under the prospective payment system, the starting date of the election depends on whether the beneficiary has regular benefit days remaining upon entering the hospital.  If the beneficiary has regu lar benefit days remaining upon entering the hospital on or after October 1, 1997, the starting date of the election must be the later of the first day after: (1) the charges equal the cost outlier threshold, or (2) the day regular benefits are exhausted.  If the beneficiary has no regular benefits remaining upon entering the hospital, the starting date of the election must be the first day of the hospital stay.   The election may specify a termination date before the last day of the stay only if the hospita l is not reimbursed under the prospective payment system and the election is made effective beginning with the first day for which reserve days are available ( 30.4.1 ).  Where the hospital is under the prospective pay ment system, the election may not specify a termination date because the election remains in effect until the last day of the stay.     40.1 - Election Format  (Rev. 257, Issued: 03- 01-19, Effective: 04-  01-19 Implementation: 04-  01-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The following model election language may be used:   Election Not To Use Lifetime Reserve Days   I do not wish to have Medicare benefits paid on my behalf under the lifetime reserve provisions of section 18l2 (b) of the Social Security Act for services furnished me by (name of hospital) beginning (date).   WHERE THE ELECTION MAY TERMINATE BEFORE THE END OF THE STAY IN ACCORDANCE WITH 40, THE FOLLOWING MAY BE INCLUDED:   The last day to which this election applies is (date).   I understand that I will be responsible for all of the hospital's charges not reimbursed by Medicare because of this election, except those covered under Medicare Part B.  Where Medicare Part B payments may be made for services furnished during the period covered by the election, I will be responsible for the deductible and 20 percent coinsurance  amounts.   (Signature) (Date)  (Medicare beneficiary identifier )  40.2 - Revocation of Election  (Rev. 1, 10- 01-03)  A3-3106.5, HO -219.5  An election not to use reserve days may be revoked in whole or in part, provided a claim has not been filed for Part B ancillary services furnished on the hospital days in question.  (An election may be revoked in part subject to the restriction on elections in 30.4.1 .  The revocation must be submitted to the hospital in writing and should be made  part of the patient's hospital record.  (See 40.2.1, below, for sample revocation format.)  If a beneficiary is incapacitated, any of the individuals who are permitted to sign the Request for Payment may file the revocation on the beneficiary's behalf.  However, an election not to use reserve days may not be revoked after the beneficiary dies.   A revocation of election not to use lifetime reserve days must be made within 90 days following the beneficiary's discharge from the hospital with the following ex ception:  The election may be revoked later than 90 days after discharge if benefits are available from a private insurer to pay the lifetime reserve coinsurance amounts and the insurer requires as a condition for payment that lifetime reserve days be used.   40.2.1 - Revocation Format  (Rev. 257, Issued: 03- 01-19, Effective: 04-  01-19 Implementation: 04-  01-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the  HICN as part of their processes.   The revocation of an election not to use reserve days should specify the name of the hospital, the admission date of the stay to which it applies and, if appropriate, the effective date of revocation.  The following model  language is suggested:   Revocation of Election Not To Use Lifetime Reserve Days   I wish to revoke the election previously made by me or on my behalf not to use lifetime reserve days to pay for the inpatient hospital services furnished me by (name of hospital) during my stay there beginning (admission date).  (If appropriate add: I wish to revoke my election not to use lifetime reserve days for the period from _____to_____.)  I understand that my lifetime reserve days will be used for these services (t o the extent that I have such days available) but that I will still be responsible to pay the Medicare coinsurance amounts and any charges for services not covered under the Medicare program.   (Signature) (Date)  (Medicare beneficiary identifier )  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R257BP   03/01/2019 Update to Publication 100- 02 Provide Language -Only Changes for the New Medicare Card Project  04/01/2019  11170  R1BP  10/01/2003 Initial Publication of Manual  NA NA Back to top of Chapter