evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
A provider qualified to start a benefit period is a hospital (including a psychiatric hospital) or SNF that meets all the requirements of the definition of such an institution.  A hospital which meets all requirements in Chapter 5, 20 of this manual is also a qualified hospital for purposes of beginning a benefit period when it furnishes the patient covered inpatient emergency services.  Thus, generally, the benefit period begins when covered inpatient services are initially furnished to an entitled individual.  However, the noncovered services furnished by a nonparticipating provider can begin a spell of illness only if the provider is a qualified provider.  A qualified provider is a hospital (including a psychiatric hospital) or a SNF  which meets all requirements in the definition of such an institution even though it may not be participating.  A qualified hospital in Canada or Mexico is also a qualified provider for purposes of beginning a benefit period when it furnishes covered inpa tient hospital services.  If a person is in a nonqualified institution and is subsequently transferred to a qualified hospital (general or psychiatric), his/her benefit period begins on admission to the qualified hospital.  Admission to a qualified SNF or to the SNF level of care in a swing- bed hospital begins a benefit period even though payment for the services cannot be made because the prior hospitalization or thirty -day transfer requirement has not been met.  It is also worth noting that the SNF benefits thirty -day transfer requirement has a medical appropriateness exception (described in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 8, section 20.2.2), under which the allowable interval between a beneficiarys discharge from a qualifying prior hospitalization and the initiation of SNF care can exceed the normal 30- day timeframe; moreover, in a situation where the allowable interval under this exception is 60 days  or longer, the subsequent commencement of extended care services in the SNF would serve to trigger the start of a new benefit period.  Inpatient care in a Religious Non- Medical Health Care Institution (whether as hospital or extended care services) can begin or prolong a benefit period.   10.4.2 - Ending a Benefit Period  (Rev. 80, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)
(Medicare General Information, Eligibility, and Entitlement)
10.4.2 - Ending a Benefit Period  (Rev. 80, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  The benefit period ends with the close of a period of 60 consecutive days during which the patient was neither an inpatient of a hospital nor of a SNF.  To determine the 60 consecutive day period, begin counting with the day the individual was discharged. (See 10.4.3.2 of this chapter for determining the end of a benefit period when an individual remains in a SNF.)   As noted in section 10.4, the term benefit period is synonymous with spell of illness.  However, t he statutory language (at 1861(a) of the Social Security Act) that describes a benefit period as a spell of illness is sometimes misunderstood to mean that a benefit period is linked to a particular medical episode or type of condition, so that the onse t of a new and entirely unrelated condition could serve to end a benefit period even in the absence of a 60 -day break in the beneficiarys inpatient statu s.  In fact, the onset of a new condition is not, in itself, relevant to the ending of a benefit period, which can occur only through a 60- day break in inpatient status, as described above.   10.4.3 - Definition of Hospital or SNF for Ending a Benefit Period  (Rev.10880, Issued: 08- 06-21, Effective: 11 -08- 21, Implementation: 11- 08-21)
(Medicare General Information, Eligibility, and Entitlement)
10.4.3 - Definition of Hospital or SNF for Ending a Benefit Period  (Rev.10880, Issued: 08- 06-21, Effective: 11 -08- 21, Implementation: 11- 08-21)  It is important to note that a benefit period cannot end while a beneficiary is an inpatient (see 10.4.4) of an institution that meets the basic definition of a hospital at 1861(e)(1) of the Social Security Act (the Act), even if the hospital does not meet all of the additional requirements that are necessary for st arting a benefit period, as discussed further in 10.4.3.1 below (see also 1861(e) following (9) of the Act and the regulations at 42 CFR 409.60(b)(1)).  Similarly, a benefit period cannot end while a beneficiary is an inpatient (see 10.4.4) of an instit ution that meets the basic definition of a SNF at 1819(a)(1) of the Act, as discussed further in 10.4.3.2 below.  As noted in 2164 of the State Operations Manual (Pub. 100- 07), Chapter 2, all hospitals and SNFs that are Medicare- certified are automatically considered to meet the applicable basic definition in this context by reason of the Medicare certification itsel f. Moreover, even an institution (or portion of an institution) that is not certified for Medicare can serve to prolong an inpatients benefit period if it meets either the basic hospital or SNF definition discussed above.   10.4.3.1 - Hospital Stay and End of Benefit Period  (Rev. 1, 09- 11-02)  In order to end a benefit period, for at least 60 consecutive days, a beneficiary cannot have been in a hospital which meets the initial requirement in the definitions in Chapter 5, 20.1 through 20.7 of this publication.  That is, the beneficiary cannot have been in a facility that is primarily engaged in providing, by or under the supervision of a physician(s), to inpatients:
(Medicare General Information, Eligibility, and Entitlement)
 Diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons or rehabilitation services for injured, disabled, or sick persons; or    Psychiatric services for the diagnosis and treatment of mentally ill persons.  A stay in a hospital outside the United States prolongs a benefit period. It may be assumed, in the absence of evidence to the contrary, that:    A foreign hospital in which a beneficiary spent one or more days meets the requirement of the definition in Chapter 5, 20 of this manual; and    The beneficiary's statement about length and place of stay is correct.   10.4.3.2 - SNF Stay and End of Benefit Period  (Rev.10880, Issued: 08- 06-21, Effective: 11 -08- 21, Implementation: 11- 08-21  Similarly, to end a benefit period, a beneficiary cannot have been an inpatient (see 10.4.4) of a SNF for at least 60 consecutive days; where SNF is defined in accordance with 1861(a)(2) and 1819(a)(1) of the Social Security Act  as a facility which is primarily engaged in providing skilled nursing care and related services to residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.  As indicated above in 10.4.3, all Medicare -certified SNFs (including Medicare -certified distinct part SNFs) are automatically considered to meet this basic SNF definition by reason of the Medicare certification itself.  See 2166 of the State Operations Manual (Pub. 100- 07), Chapter 2, for the administrative criteria used in determining whether the basic SNF definition is met by a nursing home that is not Medicare- certified (including the noncertified portion of an institution that also contains a Medicare- certified distinct part SNF).
(Medicare General Information, Eligibility, and Entitlement)
Examples: An individual may be discharged from and readmitted to a hospital or SNF several times during a benefit period and still be in the same benefit period if 60 consecutive days have not elapsed between discharge and readmission.  The stays need not be for related physical or mental conditions.  Example 1: X was born 8/9/1936. On 7/28/2001, X entered a participating general hospital. After he/she had been in the hospital for 2 weeks, X was discharged on 8/11/2001.  On his/her doctors orders, X entered a participating SNF on 8/15/2001, and remained an inpatient there (see 10.4.4) until his/her discharge on 10/27/2001.  He/she had no further inpatient stays in 2001.  Xs benefit period began on 8/1/2001, the first day of the month he/she attained age 65 and was entitled to hospital insurance.  The benefit period ended 12/25/2001, the end of the 60- day period beginning with the date of his/her last discharge.   Example 2: Y, over age 65, entered a participating general hospital on 8/28/2000 for treatment of a heart condition.  He/she was discharged on 9/11/2000.  On 10/3/2000, Y entered a Medicaid -only nursing facility, and remained an inpatient of this facility (see 10.4.4) until his/her discharge on 11/17/2000. On 12/26/2000, Y was again admitted to a participating hospital because of injuries suffered in an accident.  He/she was discharged on 1/13/2001 and had no further inpatient stays in 2001.  Ys benefit period began on 8/28/2000.  His/her stay in the nursing facility began less than 60 days after his/her hospital stay and the benefit period was continued because he/she remained an inpatient there (see 10.4.4) even though Medicare did not cove r the stay.  The subsequent hospital stay began less than 60 days after the nursing facility stay and continued the benefit period although the condition treated was unrelated to his/her prior stays.  The benefit period ended on 3/14/2001, the end of the 60- day period beginning with the day of last discharge.
(Medicare General Information, Eligibility, and Entitlement)
Example 3: Z, over age 65 and entitled to hospital insurance benefits, was admitted to General Hospital on 8/l/2000 and discharged on 8/10/2000, having received nonemergency hospital services.  General Hospital met all the requirements in the definition of  a hospital except those concerning utilization review and health and safety.  While General Hospital met the minimum requirements of an emergency hospital, Zs benefit period did not begin with his/her admission to this hospital because:   1. The hospital did not meet all of the requirements in the definition of a hospital; and   2. Although the hospital satisfied the minimum requirements for coverage of emergency services, Z did not receive emergency inpatient care there.   (As noted previously, a stay in an emergency hospital does not begin a benefit period unless it actually involves the receipt of covered inpatient emergency services; by contrast, even a nonemergency stay in such a hospital can serve as a qualifying hospit al stay for purposes of coverage under the posthospital extended care benefit.)  Z was admitted to Haven Convalescent Home on 8/20/2000 and remained an inpatient of the home (see 10.4.4) until his/her discharge on 3/1/2001.  He/she had no further inpatient stays in 2001.  Haven Convalescent Home became a participating SNF on 1/1/2001.  Z's benefit period began 1/1/2001, the day Haven Convalescent Home was determined to be a qualified SNF.  The services Z received from that date through discharge were extended care services even though they were not covered and, therefore, not charged against Zs Medicare SNF utilization.  (The services were not covered posthospital extended care services because Z was not admitted to a participating SNF within 30 days after discharge from the hospital.)  Zs benefit period ended 4/29/2001, the end of the 60-day period beginning with the date of his discharge from the convalescent home.  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)
(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.
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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.