Under the guarantee of payment provision, a participating hospital may be paid for inpatient hospital services furnished on behalf of a beneficiary whose benefit days have been exhausted (including the 190-day lifetime limit on inpatient psychiatric hospital services). The guarantee of payment provision does not apply until the individual has exhausted their 60 lifetime reserve days except where the average daily charge is equal to, or less than the lifetime reserve day coinsurance amount, since in such cases the reserve days cannot be used by the beneficiary. (See HI 00601.065).

The guarantee applies only to inpatient hospital services furnished by a participating hospital, whether general, psychiatric, or tuberculosis. The provision assures that payment will be made to a hospital for services furnished during the time it takes to ascertain the patient’s eligibility from the utilization record.

Benefits are payable under the guarantee if the patient’s benefit days were exhausted before the intermediary’s reply to the notice of admission reached the hospital. This includes those situations in which benefit days were exhausted prior to admission and where a beneficiary had some benefit days remaining at the time of their admission, e.g., two or three days of eligibility, but these were exhausted before the intermediary’s reply to the notice of admission reached the hospital. Payment under the guarantee is made at the full rate; that is, the hospital receives payment without any reduction for coinsurance. A hospital is not required to claim payment under the guarantee provision; it may look to the patient for payment.

The intermediary may pay for covered inpatient hospital services for up to 6 days after the day of admission. Saturdays, Sundays, Federal legal holidays, and the days of admission are omitted in computing the six elapsed days.

Payment may not be made for any day after the day the hospital receives notice from any source of the exhaustion of the beneficiary’s benefits.

Benefits paid to a hospital under the guarantee provision are subject to recovery from the beneficiary and/or third party payers, by the intermediary, and by CMS, in the same way as other overpayments for which beneficiaries are liable.