Duration of Covered Inpatient Services

Published 02/07/2025

Benefit Period (Spell of Illness)

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. 

Medicare Part A formula

60 Full Days + 30 Coinsurance Days = Maximum Benefit Period

Note: The benefit period is renewed when the beneficiary has not been an inpatient of a hospital or of a skilled nursing facility (SNF) for 60 consecutive days. 

Inpatient 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. For more information, see  Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 5, Section 10  (PDF)

Posthospital Extended Care Days 

A patient having hospital insurance coverage is entitled to have payment made on his/her behalf for up to 100 days of covered inpatient extended care services in each benefit period, subject to the coinsurance requirements described in IOM, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement, Deductibles, Coinsurance Amounts, and Payment, Chapter 3, Section 10.3, Section 10.4.4. (PDF)

Counting Inpatient Days 

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. 

Inpatient Day Formula

A Part of a day + The day of Admission + Day on which a patient returns from leave of absence = Counts as a full day

Note: 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.

Late Discharge 

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. 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 IOM Pub. 100-04,  Medicare Claims Processing Manual, Chapter 30, Section 50 (PDF) for instructions about ABNs.

When 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. 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
  • 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. 

Note: The Quality Improvement Organization is responsible for reviewing the appropriateness of early discharges. 

Leave of Absence

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. For more information on reporting inpatient leave of absence on a claim, refer to:

Discharge or Death on First Day of Entitlement or Participation

The cost for SNF services has been built into the SNF Medicare Prospective Payment System (PPS) base. This makes the PPS per diem somewhat higher than it would have been for all preceding SNF days that Part A does cover, even though the day of discharge itself is not a covered Medicare 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
  • 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, follow the rules in IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 3, Section 20.1.1  (PDF).

Medicare does not pay for accommodations or SNF services 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.

Inpatient Days Counting Toward Benefit Maximums

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
  • Payment cannot be made because the inpatient deductible or coinsurance is higher than the charges

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. Per the IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 5 (Lifetime Reserve Days, Section 10.2, and Section 30, 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:

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).

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
  • 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

Note: 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.

References


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