HI 00601.090 Limitation on Inpatient Psychiatric Benefits in Initial Benefit Period

A. General

If an individual is in a participating psychiatric hospital on the first day of his entitlement to hospital insurance, the number of inpatient benefit days in the first benefit period may be reduced. The days (not necessarily consecutive) on which he was an inpatient of a psychiatric hospital in the 150 day period immediately before the first day of entitlement, must be subtracted from the 150 days of inpatient hospital services for which he would otherwise be eligible in his first benefit period. Days spent in a general hospital for diagnosis or treatment of a psychiatric condition prior to entitlement will not reduce the patient's inpatient benefit days in his initial benefit period.

The reduction applies only to inpatient hospital services received in a psychiatric hospital, or in a general hospital if the individual is an inpatient of the general hospital primarily for the diagnosis or treatment of mental illness. Thus, for example, if a patient in a psychiatric hospital has no benefit days remaining because of the reduction, he may nevertheless be entitled to have payment made for up to 150 days of inpatient hospital services for a non-mental illness during his first benefit period.

B. Determining days available

The patient will be eligible to have payment made for inpatient psychiatric hospital services and inpatient hospital services primarily for the diagnosis or treatment of mental illness in the first benefit period only for the number of days remaining after the reduction is applied. To determine the number of days available in the first benefit period to pay for inpatient psychiatric hospital services and inpatient hospital services for the treatment of mental illness, take the following steps:

  1. determine how many days in the 150 day preentitlement period the patient spent in a psychiatric hospital

  2. subtract these from 150.

    Payment is made for the remaining days in the following order of priority:

    1. the 60 full benefit days,

    2. the 30 coinsurance days at one quarter the inpatient hospital deductible,

    3. the 60 lifetime reserve days at one half the inpatient hospital deductible.

Benefit days, including lifetime days, not available to the patient because of the psychiatric limitation nevertheless remain available for use in hospitalization not subject to the reduction: a general hospital stay for a nonpsychiatric condition or a tuberculosis hospital stay. The lifetime days not previously used also remain available for any inpatient stays (including psychiatric hospital stays) in subsequent benefit periods.

Example 1:

James Powers was an inpatient of a participating psychiatric hospital on his first day of entitlement on February 1, 1981 He had been in such a hospital in the preentitlement period for 20 days. Therefore, 130 days are payable. Payment would be made in the following order: 60 full benefit days; 30 $51 coinsurance days; 40 $102 coinsurance (lifetime) days.

Example 2:

The same facts as example 1, except that Mr. Powers had been in a psychiatric hospital in the preentitlement period for 70 days. Therefore, 80 days are payable. Payment would be made in the following order: 60 full benefit days; 20 $51 coinsurance days.

Example 3:

The same facts as in example 1, except that Mr. Powers had been in a psychiatric hospital in the preentitlement period for 110 days. Therefore, 40 days are payable. Payment would be made for these 40 days at full benefit.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600601090
HI 00601.090 - Limitation on Inpatient Psychiatric Benefits in Initial Benefit Period - 04/03/2015
Batch run: 04/03/2015
Rev:04/03/2015