Effective Dates: 10/25/2022 - Present Previous | Next

TN 5 (10-22)

HI 00601.001 Scope of Benefits

Beneficiaries covered under Part A of Medicare are entitled to the following services, when such services are medically necessary.

A. Inpatient hospital services

In each benefit period (spell of illness) payment may be made for up to 90 days of patient care in any participating general care, or psychiatric hospital. Payment may not be made for more than a total of 190 days of psychiatric hospital services during the patient's lifetime. In each benefit period, hospital insurance pays for all covered services for the first 60 days, except for an inpatient hospital deductible which is determined annually by the Secretary. (See HI 00601.550).

For the 61st through the 90th day hospital insurance pays for all covered services, except for a daily coinsurance amount which is one quarter of the inpatient hospital deductible. (See HI 00601.560.A).

Each beneficiary also has a “lifetime reserve” of 60 additional hospital days. They can elect to use these days after their 90th inpatient day stay. The beneficiary's “lifetime” reserve pays for all covered services, except for a daily coinsurance amount which is one-half of the initial deductible. (See HI 00601.560.B).

In addition to the inpatient hospital deductible there is also a blood deductible of the first three pints of blood in each benefit period.

Payment may be made for emergency inpatient hospital services furnished by nonparticipating hospitals when such services are necessary to prevent the death or serious impairment of the health of the individual and because the threat to the life or health of the individual necessitates the use of the most accessible hospital. (See HI 01201.201.) (Emergency outpatient services are covered under Medicare Part B.)

B. Skilled Nursing Facility (SNF) services

A patient no longer in need of intensive hospital care may still require daily skilled nursing or rehabilitation services which, as a practical matter, can only be provided in an SNF. The Hospital Insurance program will pay for these services if they are provided in Medicare participating SNFs. Generally, the patient must be admitted within 30 days after discharge from a qualifying 3-day hospital stay (see HI 00601.130).

In each benefit period the hospital insurance plan pays for all covered services provided in a participating SNF during the first 20 days and all but daily coinsurance amount which consists of one-eighth of the inpatient hospital deductibles for up to 80 additional days. (See HI 00601.480).

C. Home Health benefits

1. Requirements prior to July 1, 1981

Following a qualifying hospital stay of at least 3 days, the doctor may decide that further care can best be given in a homebound patient's home through a participating home health agency (HHA). If the patient requires intermittent skilled nursing care or physical or speech therapy, and otherwise qualifies for home health benefits, they are also eligible to receive certain other home health services. These services include occupational therapy, medical social services, the use of medical supplies and medical appliances, and the part-time services of home health aides.

Hospital insurance can pay for home health visits if a patient's doctor establishes a home health plan within 14 days after discharge from a hospital or participating SNF and the care is for further treatment of a condition which was treated in a hospital or participating SNF.

Under these conditions, Hospital Insurance can pay the full cost of up to 100 home health visits after the start of the benefit period and before the start of another. Payment for these visits can be made for up to 12 months after the most recent discharge from a hospital or participating SNF.

2. Requirements beginning July 1, 1981

Effective 7/1/81, the prior inpatient stay requirements, the 100 visit limitation, and the spell of illness requirements are eliminated. Also, a patient can qualify for home health benefits if they requires occupational therapy.

3. Requirements beginning December 1, 1981

Effective December 1, 1981, occupational therapy is eliminated as a basis for entitlement to home health services. However, if a person has otherwise qualified for home health services because of the need for skilled nursing care, physical therapy or speech therapy, the patient's eligibility for home health services may be extended solely on the basis of the continuing need for occupational therapy.

D. Hospice care

In lieu of certain other benefits, payment may be made for hospice care during up to two periods of 90 days each and one subsequent period of 30 days if an individual elects to receive hospice care. (See HI 00601.295.)

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0600601001
HI 00601.001 - Scope of Benefits - 10/25/2022
Batch run: 10/25/2022
Rev:10/25/2022