evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
For discharges before October 1, 1997, cost outlier status has no impact on reserve days, but the following rules applied for day outlier claims.  Day outliers were discontinued for discharges on and after October 1, 1997.   See the Medicare Claims Processing Manual, Chapter 1, Inpatient Ho spital Services, for billing and payment requirements.   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 (Rev. 1, 10- 01-03)  A3-3106.2.D.2.a, HO -219.2.D.2.a  The section applies to discharges before the outlier policy was changed effective October 1, 1997, to eliminate day outliers.  If the beneficiary has one or more regular benefit days (not lifetime reserve days) remaining in the benefit period upon entering the  acute or rehabilitation hospital, Medicare will pay the entire prospective payment amount for nonoutlier days.  Therefore, there will be no advantage to a beneficiary to use lifetime reserve days for nonoutlier days if at least one day of the regular 90 d ays of coverage remains when the beneficiary enters the hospital.  In this situation, the beneficiary will be deemed to have elected not  to use lifetime reserve days for the nonoutlier part of the stay.  The beneficiary may also elect not to use lifetime r eserve days for outlier days but such an election must apply to all outlier days.   NOTE:  This policy is not applicable to Long Term Care Hospital PPS short stay outliers.  See 30.6  for the LTCH PPS short stay outlier L TR policy.   EXAMPLE 3:
(Medicare Benefit Policy Manual)
NOTE:  This policy is not applicable to Long Term Care Hospital PPS short stay outliers.  See 30.6  for the LTCH PPS short stay outlier L TR policy.   EXAMPLE 3:   Mr. Spencer was admitted to a hospital on April 1, 1995, and discharged on June 29, utilizing 89 regular days of inpatient care.  On August 1, he entered the hospital again.  For this DRG, outlier days would have begun August 26, but Mr. Spencer was discharged on August 23, prior to the commencement of outlier days.  Since the first two days of the second stay were regular coverage days, Medicare will reimburse the hospital the prospective reimbursement amount for the entire stay.  S ince no outlier days are involved, there is no advantage to the beneficiary in using lifetime reserve days.  Therefore, Mr. Spencer will be deemed to have elected not  to use any lifetime reserve days for that stay.   Even though lifetime reserve days are not used for nonoutlier days where the beneficiary has at least one regular day available at the time of admission, payment will be made for outlier days occurring after regular coverage days have been exhausted unless:   a. The beneficiary elects not to use lifetime reserve days for the outlier days; or   b. The beneficiary is deemed to have elected not to use lifetime reserve days for the outlier days.   A beneficiary is deemed to have elected not to use lifetime reserve days  for outlier days if the average daily charge for the outlier days for which lifetime reserve days would otherwise be available is equal to or less than the daily coinsurance amount for the lifetime reserve days.  In that situation, the beneficiary would b e required to pay for all of the hospital's charges for such outlier days regardless of his or her election and therefore would not benefit from the use of lifetime reserve days.  If the beneficiary elects not to use lifetime reserve days for outlier days,  such an election must apply to all outlier days.  If the beneficiary elects not to use lifetime reserve days for outlier days Medicare will pay for the nonoutlier portion of the stay and will make no payment for the outlier days.   EXAMPLE 4:
(Medicare Benefit Policy Manual)
EXAMPLE 4:   Mr. Johnson, who had never used any of his lifetime reserve days, was admitted to the hospital on April 1, 1995, and discharged on June 29, utilizing 89 regular days of covered inpatient care.  On August 1, Mr. Johnson entered the hospital again and was discharged on September 5.  For this DRG, outlier days began on August 26.  Medicare will reimburse the hospital the prospective payment amount for the nonoutlier portion of the stay.  The average daily charges were $450 for the outlier portion of the stay.  The lifetime reserve day coinsurance amount is $406.  Since the average daily charge for the outlier days is more than the daily coinsurance amount for lifetime reserve days, there is no deemed election not to use lifetime reserve days for the outlier portion of the stay.  For outlier days Mr. Johnson has the option:   1. To make no lifetime reserve election, in which case Medicare will pay for the nonoutlier portion of the stay and for the 10 outlier days, August 26 through September 4, and Mr. Johnson will have utilized 10 lifetime reserve days; or   2. To elect not  to use his lifetime reserve days for the 10 outlier days, in which case Medicare will pay only for the nonoutlier portion of the stay, and Mr. Johnson will not have used any lifetime reserve days.   30.4.2.2 - Beneficiary Has No Regular Days Available at Time of Admission - Discharge Before October 1, 1997  (Rev. 1, 10- 01-03) A3-3106.2.D.2.b, HO -219 .2.D.2.b
(Medicare Benefit Policy Manual)
If the beneficiary enters the hospital after completely exhausting regular benefit days, available lifetime  reserve days will be used automatically for each day of the stay unless the beneficiary elects not to use lifetime reserve days or is deemed to have elected not to use lifetime reserve days.  A beneficiary is deemed to have elected not to use lifetime reserve days if the total charges for the stay, i.e., the charges for which the beneficiary would be liable by electing to not use lifetime reserve days, are equal to or less than the charges for which the beneficiary would be liable even after electing to us e lifetime reserve days.  In the latter case, charges are equal to 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 be cause lifetime reserve days are exhausted.  (See 30.1(3) .)  In the case of a hospital reimbursed under the prospective payment system, an election by a beneficiary not to use lifetime reserve days must apply to the entire hospital stay.  If the beneficiary elects not to use lifetime reserve days, Medicare will not pay for any portion of the stay.  Similarly, a deemed election not to use lifetime reserve days must apply to the entire stay and will preclude any payment for th e stay.   EXAMPLE 5:   Mr. Amos was admitted to a hospital on March 10, 1995, and discharged on June 8 utilizing 90 regular days of coverage.  On August 1, he entered the hospital again and was discharged on September 8.  For this DRG, outlier days began on August 26.  At the time of the second admission, Mr. Amos still had 60 lifetime reserve days available.  The hospital charges for this stay were $17,000.  The sum of the coinsurance amounts for the lifetime reserve days needed to pay for this stay is $15,428 ($406 per day X 38 days).  Since the charges for the stay are greater than the sum of lifetime reserve days coinsurance amounts, there is no deemed election not to use lifetime reserve days.  Mr. Amos has the option:   1. To make no lifetime reserve electio n, in which case Medicare will pay for the entire stay including the outlier days, and Mr. Amos will use 38 lifetime reserve days; or
(Medicare Benefit Policy Manual)
1. To make no lifetime reserve electio n, in which case Medicare will pay for the entire stay including the outlier days, and Mr. Amos will use 38 lifetime reserve days; or   2. To elect not  to use lifetime reserve days, in which case Medicare will not pay for any portion of the stay.   EXAMPLE 6:   Same facts as Example 5 except the beneficiary has only 35 lifetime reserve days available at the time of the second admission and total charges for the stay are $13,000.  Included in the hospital charges is $1,200 for the last 3 days of the stay.  The sum of the coinsurance amounts for the lifetime reserve days that could be used is $14,210 ($406 per day X 35 days).  Since the charges for the entire stay, $13,000, are less than $15,410 (the sum of the coinsurance amounts for days for which lifetime reserv e days are available ($14,210) plus the total charges for the outlier days for which lifetime reserve days are not available ($1,200)), the beneficiary is deemed to have elected not to use any lifetime reserve days for the stay.   30.5 - Election Where Bene ficiary Is Incapacitated  (Rev. 1, 10- 01-03)  A3-3106.2.E, HO -219.2.E   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)
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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)
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 6 - Hospital Services Covered Under Part B   Table of Contents  (Rev. 12421; Issued;  12-21-23) (Rev. 12425; Issued; 12-21-23)  Transmittals for Chapter 6   10 - Medical and Other Health Services Furnished to Inpatients of Participating Hospitals  10.1 - Reasonable and Necessary Part A Hospital Inpatient Claim Denials  10.2  Other Circumstances in Which Payment Cannot Be Made Under Part A  10.3  Hospital Inpatient Services Paid Only Under Part B  20 - Outpatient Hospital Services  20.1 - Limitation on Coverage of Certain Services Furnished to Hospital Outpatients  20.1.1 - General Rule  20.1.2 - Exception to Limitation  20.2 - Outpatient Defined  20.3 - Encounter Defined  20.4 - Outpatient Diagnostic  Services  20.4.1 - Diagnostic Services Defined 20.4.2 - Reserved  20.4.3 - Coverage of Outpatient Diagnostic Services Furnished on or Before December 31, 2009  20.4.4 - Coverage of Outpatient Diagnostic Services Furnished on or After January 1, 2010  20.4.5 - Outpatient Diagnostic Services Under Arrangements  20.5  Outpatient Therapeutic Services  20.5.1 - Coverage of Outpatient Therapeutic Services Incident to a Physician's Services Furnished on or After August 1, 2000 and Before January 1, 2010 20.5.2 - Coverage of Outpatient Therapeutic Services Incident to a Physician's Services Furnished on January 1, 2010 through December 31, 2019                         20.5.3 - Coverage of Outpatient Therapeutic Services Incident to a              Physicians Service Furnished on or After January 1, 2020 -  Changes to            Supervision Requirements                         20.5.4 Coverage of Outpatient Therapeutic Services Incident to a                          Physicians    Service Furnished on or After January 1, 2024  Changes to                        Direct Supervision Requirements for Pulmonary, Cardiac and Intensitv                          Cardiac   Rehabilitation   20.6 -  Outpatient Observation Services  30 - Drugs and Biologicals  40 - Other Covered Services and Items  50 - Sleep Disorder Clinics  60 - Intermittent Peritoneal Dialysis Services  70 - Outpatient Hospital Psychiatric Services  70.1 -  General  70.2 -  Coverage Criteria for Outpatient Hospital Psychiatric Services  70.3 -  Partial Hospitalization Services
(Medicare Benefit Policy Manual)
70.4 -  Intensive Outpatient Services   70.5 -  Laboratory Services Furnished to Nonhospital Patients by Hospital Laboratory  80 - Rental and Purchase of Durable Medical Equipment  90 - Services of Interns And Residents  10 - Medical and Other Health Services Furnished to Inpatients of Participating Hospitals  (Rev. 182, Issued: 03- 21-14, Effective: 10 -01-13, Implementation: 04- 21-14)  Payment may be made under Part B for physician services and for the nonphysician medical and other health services as provided in this section when furnished by a participating hospital (either directly or under arrangements) to an inpatient of the hospital, but only if payment for these services cannot be made under Part A.  This policy applies to all hospitals and critical access hospitals (CAHs) participating in Medicare, including those paid under a prospective payment system or alternative payment methodology such as State cost control systems, and to emergency hospital services furnished by nonparticipating hospitals.  In this section, the term hospital includes all hospitals and CAHs, regardless of payment methodology, unless otherwise specified.   For services to be covered under Part A or Part B, a hospital must furnish nonphysician services to its inpatients directly or under arrangements (see chapter 16, 170 of this manual, Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider).  A nonphysician service is one which does not meet the criteria defining physicians services specifically provided for in regulation at 42 CFR 415.102. Services "incident to" physicians services (except for the services of nurs e anesthetists employed by anesthesiologists) are nonphysician services for purposes of this provision.  10.1 - Reasonable and Necessary Part A Hospital Inpatient Claim Denials  (Rev. 182, Issued: 03- 21-14, Effective: 10 -01-13, Implementation: 04- 21-14)