Hospital and Lifetime Reserve Essay

Medicare Benefit Policy Manual
Chapter 5 - Lifetime Reserve Days

Table of Contents

Crosswalk to Old Manual
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 OneHalf 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 the 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 not 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 Average 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 all 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 - Availability 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

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