what usually counts.
At the same time, Medicare has always placed limits on certain areas of coverage — and although Washington policymakers may regard these caps as reasonable attempts to rein in runaway costs and guard against fraud, the limits can adversely affect some patients. So on the basis that forewarned is forearmed, the following sections provide an overview of the four main areas where coverage comes with limits: stays in the hospital, stays in a skilled nursing facility, mental health benefits, and therapy services.
Limits on hospital stays
Most people these days don’t spend more than a few days in the hospital, and the fear of catching a really bad hospital infection — known as a leading cause of death — is enough to make anyone want out of there as soon as possible. So the chances that you’ll exhaust Medicare coverage during a hospital stay are remote. Still, in case you get sick enough to need a long spell in the hospital, the following sections clue you in to how the limits work.
If you’re enrolled in traditional Medicare
If you need to stay for a long period in the hospital for one spell of illness that’s known as a benefit period, Medicare will cover 100 percent of your nursing and living costs for the first 60 days after you’ve met a deductible. For days 61 to 90, you’re required to pay a daily co-pay. (I explain these costs in Chapter 3, and I go into detail about benefit periods in Chapter 14.)
No limit caps the number of benefit periods you can have, provided that 60 days have elapsed between each one. But if you still need to be in the hospital longer than 90 days in any one benefit period, you must either pay the full cost yourself or draw on up to 60 more days for which you pay hefty daily co-pays. These 60 days are called lifetime reserve days. You can use as many as you want or save some in case you need them in the future. But as the phrase implies, when you’ve used them, they’re gone for good.
However, all Medigap supplemental insurance policies (explained in Chapter 4) extend Part A hospital coverage for up to an additional 365 days in your lifetime after Medicare benefits are exhausted. And most Medigap policies pay for the Part A hospital deductible, too. If you’re enrolled in Medicaid (state medical assistance), this program usually covers the co-pays for lifetime reserve days.
If you’re enrolled in a Medicare Advantage health plan
Medicare Advantage plans usually have a simpler system for charging for hospital stays. Often they charge a daily co-pay for the first several days and nothing for the remaining days. Most plans set no limits on the number of days they cover, so you don’t need to draw on lifetime reserve days. But some plans do set limits, although sometimes they charge no co-pays for the lifetime reserve days. Comparing the differences between Medicare Advantage plans and traditional Medicare when it comes to hospital stays is an important topic that I discuss in Chapters 9 and 11.
Limits on skilled nursing facility stays
If you need continuing skilled nursing care after you’ve been in the hospital and meet certain conditions (as explained earlier in this chapter and in Chapter 14), Medicare covers a stay in a skilled nursing facility — but it comes with limits. Beyond 100 days in each benefit period, you’ll pay the full cost unless you have additional insurance. Some or all of these costs may be covered if you have additional insurance coverage through Medicaid, employer health benefits, long-term-care insurance, or Medigap supplemental insurance. Check your policy to find out. Most Medicare Advantage plans also limit coverage to 100 days in a benefit period.
Limits on mental health benefits
Like many other insurance plans, Medicare treats care for mental health disorders differently from other health problems. This kind of discrimination is less common than it used to be in Medicare, but some limits are still placed on mental health benefits, as described in the following sections.
Outpatient psychiatric services
In the past, traditional Medicare charged more than twice as much for seeing a mental health professional as an outpatient than for seeing any other kind of doctor — co-pays of 50 percent of the cost of a visit rather than 20 percent. But since 2010, under a law passed in 2008, those co-pay costs have gradually come down. Today, you pay the standard 20 percent co-pay for outpatient psychiatric care, and Medicare pays the rest, as long as you see a participating provider. If you have Medigap insurance, these co-pays are covered. If you’re in a Medicare Advantage plan, you pay what your plan requires.
Psychiatric care in a hospital
The 2008 health-care law didn’t change a discriminatory situation in which Medicare patients are limited to 190 days over their lifetime for receiving inpatient treatment in psychiatric hospitals — those that specialize in mental health conditions. Yet Medicare places no such limit on care in general hospitals. So any days you spend in a non-psychiatric hospital — even if you’re being treated for a mental health condition — don’t count toward the 190-day lifetime limit.
In some circumstances, Medicare covers partial hospitalization, which means receiving treatment at a hospital’s outpatient department or clinic or at a community mental health center during the day, but not spending the night there. Your costs for this type of service vary according to the treatment provided, but under Medicare rules it can’t be more than 40 percent of the Medicare-approved amount.
www.medicare.gov/Pubs/pdf/11358-Medicare-Mental-Health-Getting-Started.pdf.
Mental health benefits in Medicare Advantage plans
Because mental health benefits may vary among Medicare Advantage plans, look at the evidence of coverage documents for your plan. But most plans stick to the same limit of 190 lifetime days for inpatient care in a psychiatric hospital.
Limits on therapy services
Medicare Part B covers physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT). Previously, Medicare limited the amount of coverage you could get for therapy services in any given year as an outpatient or in a hospital outpatient department or emergency room, known as the therapy cap; however, in 2019, Medicare removed the cap, covering outpatient therapy at 80 percent of the Medicare-approved amount. When you receive services from a participating provider, you
