100-02 Medicare Benefit Policy Manual: Chapter 3 - Duration of Covered Inpatient Services

Medicare Benefit Policy Manual
Chapter 3 - Duration of Covered Inpatient Services
Table of Contents
(Rev. 261; Issued: 10-04-19)
Transmittals for Chapter 3
Crosswalk to Old Manual
10 - Benefit Period (Spell of Illness)
20 - Inpatient Benefit Days
20.1 - Counting Inpatient Days
20.1.1 - Late Discharge
20.1.2 - Leave of Absence
20.1.3 - Discharge or Death on First Day of Entitlement or Participation
30 - Inpatient Days Counting Toward Benefit Maximums

10 - Benefit Period (Spell of Illness)
(Rev. 261, Issued_10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
A3-3035, HO-215
A “Benefit period” is a period of consecutive days during which medical benefits for
covered services, with certain specified maximum limitations, are available to the
beneficiary. Under Part A, 60 full days of hospitalization plus 30 coinsurance days
represent the maximum benefit period. The benefit period is renewed when the
beneficiary has not been an inpatient of a hospital or of a SNF (see §20.B) for 60
consecutive days. Refer to Pub.100-01, Medicare General Information, Eligibility, and
Entitlement Manual, Chapter 3, “Deductible, Coinsurance Amounts, and Payment
Limitations” for additional information on benefit periods.
20 - Inpatient Benefit Days
(Rev. 261, Issued_10-04-19, Effective: 11-05-19, Implementation: 11-05-19)
A3-3103, A3-3135, HO-216, SNF-242
A. Inpatient Hospital Benefit Days
A patient having hospital insurance coverage is entitled, subject to the inpatient
deductible and coinsurance requirements, to have payment made on his/her behalf for up
to 90 days of covered inpatient hospital services in each benefit period. Also, the patient
has a lifetime reserve of 60 additional days (see Chapter 5, §10).
B. Posthospital Extended Care Days
A patient having hospital insurance coverage is entitled (subject to the coinsurance
requirements described in detail in Pub. 100-01, Medicare General Information,
Eligibility, and Entitlement Manual, Chapter 3, “Deductibles, Coinsurance Amounts, and
Payment Limitations”) to have payment made on his/her behalf for up to 100 days of
covered inpatient extended care services in each benefit period.
Refer to Pub. 100-01, Medicare General Information, Eligibility, and Entitlement
Manual, Chapter 3, §10.4.4 for the definition of SNF inpatient for benefit period
purposes.
20.1 - Counting Inpatient Days
(Rev. 1, 10-01-03)
A3-3103.1, A3-3104.3, A3-3135.1, HO-217.3, HO-216.1, SNF-242.1
The number of days of care charged to a beneficiary for inpatient hospital or skilled
nursing facility (SNF) care services is always in units of full days. A day begins at
midnight and ends 24 hours later. The midnight-to-midnight method is to be used in

counting days of care for Medicare reporting purposes even if the hospital or SNF uses a
different definition of day for statistical or other purposes.
A part of a day, including the day of admission and day on which a patient returns from
leave of absence, counts as a full day. However, the day of discharge, death, or a day on
which a patient begins a leave of absence is not counted as a day unless discharge or
death occur on the day of admission. If admission and discharge or death occur on the
same day, the day is considered a day of admission and counts as one inpatient day.
Charges for ancillary services on the day of discharge or death or the day on which a
patient begins a leave of absence are covered.
20.1.1 - Late Discharge
(Rev. 1, 10-01-03)
A3-3103.2, A3-3135.2, HO-216.2, SNF-242.2
When a patient chooses to continue to occupy hospital or SNF accommodations beyond
the checkout time for personal reasons, the hospital or SNF may charge the beneficiary
for the continued stay. Such a stay beyond the checkout time, for the comfort or
convenience of the patient, is not covered under the program, and the hospital's or SNF's
agreement to participate in the program does not preclude charging the patient. However,
the hospital must provide the beneficiary with an Advance Beneficiary Notice (ABN)
before the noncovered services are provided. See Medicare Claims Processing Manual,
chapter 30, for instructions about ABNs.
Where the patient's medical condition is the cause of the stay past the checkout time (e.g.,
the patient needs further services, is bedridden and awaiting transportation to their home
or in the case of a hospital, transfer to a skilled nursing facility, or dies in the SNF or
hospital), the stay beyond the discharge hour is covered under the program and the
hospital or SNF may not charge the patient.
The imposition of a late checkout charge by a hospital or SNF does not affect the
counting of days for:
• 	Ending a benefit period;
• 	The number of days of inpatient care available to the individual in a hospital or
SNF; and
• 	The 3-day prior hospitalization requirement for coverage of post hospital
extended care services and Part A home health services.
A late charge by a hospital does not affect counting of days for meeting the prior
inpatient stay requirement for coverage of extended care services.
The Quality Improvement Organization is responsible for reviewing the appropriateness
of early discharges.

20.1.2 - Leave of Absence
(Rev. 1, 10-01-03)
A3-3103.3, A3-3135.3, HO-216.3, SNF-242.3
The day on which the patient began a leave of absence is treated as a day of discharge,
and is not counted as an inpatient day unless the patient returns to the facility by midnight
of the same day. The day the patient returns to the hospital or SNF from a leave of
absence is treated as a day of admission and is counted as an inpatient day if the patient is
present at midnight of that day.
Refer to the Medicare Claims Processing Manual, Chapter 3, “Inpatient Hospital
Services,” or the Medicare Claims Processing Manual, Chapter 6, “SNF Inpatient
Billing,” as appropriate, for reporting inpatient leave of absence on the Medicare claim.
20.1.3 - Discharge or Death on First Day of Entitlement or Participation
(Rev. 1, 10-01-03)
A3-3103.4, A3-3135.4, HO-216.4, SNF-242.4
For SNF services, the cost of such services has been built into the SNF PPS base. This
makes the PPS per diem somewhat higher than it would otherwise have been for all of the
preceding SNF days that Part A does cover, even though the day of discharge itself is not
a covered Part A day:
• 	A patient is admitted prior to the first day of entitlement and dies or is discharged
from a participating hospital on the first day of entitlement; or
• 	A patient in a noncovered stay in a nonparticipating hospital dies or is discharged
on the first day the hospital becomes a participating hospital. For a late discharge
on such a day, the rules in §20.1.1 will be followed.
For SNF services, Medicare does not pay for accommodations on the day of discharge or
death. Medicare pays for ancillary services (under Part A) when a patient dies or is
discharged on the first day a facility becomes a participating facility and the other
requirements for coverage of extended care services are met.
Although a day of utilization is not counted in these situations, a benefit period begins
and any charges for covered services are applied against the inpatient hospital deductible.
30 - Inpatient Days Counting Toward Benefit Maximums
(Rev. 1, 10-01-03)
A3-3107, A3-3136, HO-216.5, SNF-244
A. 90-Day Benefit Limitation

Inpatient hospital (including psychiatric hospital) services count toward the maximum of
90 benefit days payable per benefit period only if:
• 	Payment for the services is made;
• 	Payment for the services would be made if a request for payment and claim were
filed properly and timely, a physician certified that the services were necessary, if
required, and the provider submitted all necessary evidence; or
• 	Payment cannot be made because the inpatient deductible or coinsurance is higher
then the charges.
B. Lifetime Reserve Days
Part A benefits allow for 60 lifetime reserve days for use after a 90-day benefit period has
exhausted. The 60 days are not renewable and may be used only once during a
beneficiary’s lifetime. Inpatient hospital services count toward the maximum of 60
lifetime reserve days under the same conditions as in subsection A except that days are
not counted if:
• 	The individual elects not to have payment made (See the Medicare Benefit Policy
Manual, Chapter 5, Lifetime Reserve Days, §30), or
• 	The coinsurance rate exceeds the daily charge. (See the Medicare Benefit Policy
Manual, Chapter 5, Lifetime Reserve Days, §10.2).
C. Lifetime Inpatient Psychiatric Hospital Limitation
Inpatient psychiatric hospital services count toward the 190-day lifetime limitation on
inpatient psychiatric hospital services only if the conditions in subsection A are met.
This limitation does not apply to inpatient psychiatric services furnished in a general
hospital (or distinct part).
D. Inpatient Post-hospital Extended Care Services Counting Toward Maximums
Post-hospital extended care services count toward the maximum number of benefit days
payable per benefit period only if:
• 	Payment for the services is made, or
• 	Payment for the services would be made if a request for payment were properly
filed, the physician certified that the services were medically necessary, and the
provider submitted all necessary evidence.

When payment cannot be made because of the extended care coinsurance requirement,
the day(s) used nevertheless count toward the beneficiary's maximum days of extended
care.

Transmittals Issued for this Chapter
Rev # 	Issue Date 	Subject 	Impl Date CR#
R261BP
10/04/2019 	Manual Updates for CR11152 Implementation
of the Skilled Nursing Facility (SNF) Patient
Driven Payment Model (PDPM)
11/05/2019 11454
R1BP 	10/01/2003 	Initial Publication of Manual 	NA 	NA
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