100-01 Medicare General Information, Eligibility and Entitlement Manual: Chapter 3 - Deductibles, Coinsurance Amounts and Payment Limitations
us-cms-medicare-manuals-pub-100-01-ge101c03100-01 Medicare General Information, Eligibility and Entitlement Manual: Chapter 3 - Deductibles, Coinsurance Amounts and Payment LimitationsGuidance
Medicare General Information, Eligibility, and Entitlement Chapter 3 - Deductibles, Coinsurance Amounts, and Payment Limitations Table of Contents (Rev. 12980; Issued: 11-25-24) Transmittals for Chapter 3 10 - Hospital Insurance (Part A) 10.1 - Inpatient Hospital Deductible 10.2 - Coinsurance 10.2.1 - Inpatient Services 10.2.2 - Durable Medical Equipment (DME) Furnished as a Home Health Benefit 10.3 - Basis for Determining the Part A Coinsurance Amounts 10.4 - Benefit Period (Spell of Illness) 10.4.1 - Starting a Benefit Period 10.4.2 - Ending a Benefit Period 10.4.3 - Definition of Hospital or SNF for Ending a Benefit Period 10.4.3.1 - Hospital Stay and End of Benefit Period 10.4.3.2 - SNF Stay and End of Benefit Period 10.4.4 - Definition of Inpatient for Ending a Benefit Period 20 - Supplementary Medical Insurance (SMI) (Part B) 20.1 - Supplementary Medical Insurance Incurred Expenses 20.2 - Part B Annual Deductible 20.3 - Part B Coinsurance 20.4 - Exceptions to Annual Deductible and Coinsurance 20.4.1 - Applications of Deductible and Coinsurance in Liability and Indemnification Situations 20.5 - Blood Deductibles (Part A and Part B) 20.5.1 - Part A Blood Deductible 20.5.2 - Part B Blood Deductible 20.5.3 - Items Subject to Blood Deductibles 20.5.4 - Obligations of the Beneficiary to Pay for or Replace Deductible Blood 20.5.4.1 - Replacement of Blood 20.6 - Part B Premium 30 - Outpatient Mental Health Treatment Limitation 40 - Limitation on Physical Therapy, Occupational Therapy and Speech-Language Pathology Services
10 - Hospital Insurance (Part A) 10.1 - Inpatient Hospital Deductible (Rev. 1, 09-11-02) The patient is responsible for a deductible amount for inpatient hospital services in each benefit period. For each year after 1991, the Secretary of the Department of Health and Human Services (DHHS) is required to set the deductible and coinsurance amounts between September 1 and September 15 of the preceding year. The deductible will be set at an amount equal to the deductible for the preceding year, changed by the same percentage as applies to PPS payment rates, and adjusted to reflect changes in real case mix. The deductible and coinsurance amounts are shown in the chart in §10.3 of this chapter. The coinsurance amount is based on the deductible applicable for the calendar year in which the coinsurance days occur. The deductible is satisfied only by charges for covered Part A services. Expenses for covered services count toward the deductible on an incurred, rather than paid, basis. Expenses incurred in one benefit period cannot be applied toward the deductible in a later benefit period. Expenses incurred in meeting the blood deductible do not count toward the inpatient hospital deductible. A reduction in benefit days resulting from confinement in a psychiatric hospital, on and immediately preceding the date of entitlement, does not affect the amount of the deductible for which the patient is responsible. If the actual charge is less than the deductible and the customary charge, the customary charge is applied to the deductible. A beneficiary is not responsible for payment of the deductible for an inpatient stay if the provider has been determined to be liable because the care was not medically necessary or because the care provided was custodial. 10.2 - Coinsurance (Rev. 1, 09-11-02) The following subsections describe coinsurance. 10.2.1 - Inpatient Services (Rev. 1, 09-11-02) In each benefit period, the patient is responsible for coinsurance amounts equal to: • One-fourth of the inpatient hospital deductible for each day of inpatient hospital services from the 61st through the 90th days; • One-half of the inpatient hospital deductible for each lifetime reserve day (the 91st through the 150th days of inpatient hospital services); and • One-eighth of the inpatient hospital deductible for each day of extended care services from the 21st through the 100th days. A beneficiary is not responsible for payment of the coinsurance for a stay if the provider has been determined to be liable because the care was not medically necessary or because the care provided was custodial. Use the chart in §10.3 of this chapter to determine the applicable coinsurance amounts. Where the actual charge to the patient for the 61st through the 90th days of inpatient hospital services is less than the applicable coinsurance amount, the coinsurance is the actual charge per day. Where the actual charge to the patient for lifetime reserve days is less than the coinsurance amount for those days, the beneficiary may be deemed to have elected not to use the days because he/she would not benefit from their utilization. 10.2.2 - Durable Medical Equipment (DME) Furnished as a Home Health Benefit
(Rev. 1, 09-11-02) The patient is responsible for 20 percent of the payment amount for DME furnished as a home health benefit. 10.3 - Basis for Determining the Part A Coinsurance Amounts (Rev. 12980; Issued:11-25-24; Effective: 01-01-25; Implementation: 01-06-25) The applicable inpatient deductible is the one in effect during the calendar year in which the patient's benefit period begins (i.e., in most cases, the year in which the first inpatient hospital services are furnished in the benefit period). Except for 1989, the coinsurance amount is based on the deductible applicable for the calendar year in which the coinsurance days occur. When Deductible and/or Coinsurance Are Applicable for Part A Inpatient Hospital- First 60 Days Deductible applicable equal to national average cost per day Inpatient Hospital- 61st thru 90th Day Coinsurance per day always equal to 1/4 of inpatient hospital deductible Inpatient Hospital- 60 Lifetime Reserve Days (nonrenewable) - 91st thru 150th day Coinsurance always equal to 1/2 of inpatient hospital deductible Skilled Nursing Facility 21st thru 100th Day Coinsurance always equal to 1/8 of inpatient hospital deductible Home Health Agency No Deductible No Coinsurance (except for 20 percent coinsurance for DME and prosthetics/ orthotics) Blood 1st 3 pints (or equivalent units of packed red blood cells) in a calendar year - combined Part A and B Hospice * a. Drugs and Biologicals b. Respite Care a. 5 percent of the cost determined by the drug copayment schedule (may not exceed $5 per prescription) b. 5 percent of the payment for a respite care day *Hospices may charge coinsurance for two services only, drugs and biologicals, and respite care. The amount of coinsurance for each prescription may not exceed $5.00. The amount for respite care may not exceed the inpatient deductible for the year in which the hospital coinsurance period began. Deductible and Coinsurance Amounts Year Part A Deductible, 1st 60 Days Part A Coinsurance, 61st- 90th Days Part A Coinsurance, 60 Lifetime Reserve Days Part A SNF Coinsurance 21st- 100th Days 1986 $492 123 246 61.50 1987 520 130 260 65.00 1988 540 135 270 67.50 1989 560 0 (1) 0 (1) 0(2) 1990 592 148 296 74.00 1991 628 157 314 78.50 1992 652 163 326 81.50 1993 676 169 338 84.50
1994 696 174 348 87.00 1995 716 179 358 89.50 1996 736 184 368 92.00 1997 760 190 380 92.00 1998 764 191 382 95.50 1999 768 192 384 96.00 2000 776 194 388 97.00 2001 792 198 396 99.00 2002 812 203 406 101.50 2003 840 210 420 105.00 2004 876 219 438 109.50 2005 912 228 456 114.00 2006 952 238 476 119.00 2007 992 248 496 124.00 2008 1,024 256 512 128.00 2009 1,068 267 534 133.50 2010 1,100 275 550 137.50 2011 1,132 283 566 141.50 2012 1,156 289 578 144.50 2013 1,184 296 592 148.00 2014 1,216 304 608 152.00 2015 1,260 315 630 157.50 2016 1,288 322 644 161.00 2017 1,316 329 658 164.50 2018 1,340 335 670 167.50 2019 1364 341 682 170.50 2020 1,408 352 704 176.00 2021 1,484 371 742 185.50 2022 1,556 389 778 194.50 2023 1,600 400 800 200.00 2024 1,632 408 816 204.00 2025 1,676 419 838 209.50 1. Coinsurance was not charged for inpatient hospital care in CY 1989 due to Catastrophic Coverage. The deductible was applied. 2. Under Catastrophic Coverage, a coinsurance payment of $25.50 was due for days 1-8 of SNF care. No SNF coinsurance was due after day 8 in 1989. 10.4 - Benefit Period (Spell of Illness) (Rev. 1, 09-11-02) A benefit period is a period of time for measuring the use of hospital insurance benefits. It is a period of consecutive days during which covered services furnished to a patient, up to certain specified maximum amounts, may be paid for by the hospital insurance plan. For example, a patient is eligible for 90 days of hospital care in a benefit period and 100
days of extended care services during the same benefit period. A patient may be eligible for as many as l50 days of hospital care in a benefit period if he/she draws on his/her lifetime reserve. As long as a person continues to be entitled to hospital insurance, there is no limit on the number of benefit periods he/she may have. The term "benefit period" is synonymous with spell of illness. Since the term "spell of illness" could connote a single illness or a particular "spell" of sickness, the term benefit period is used in communications with the public. 10.4.1 - Starting a Benefit Period (Rev. 80, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13) A benefit period begins with the first day (not included in a previous benefit period) on which a patient is furnished inpatient hospital or extended care services by a qualified provider in a month for which the patient is entitled to hospital insurance benefits. A provider qualified to start a benefit period is a hospital (including a psychiatric hospital) or SNF that meets all the requirements of the definition of such an institution. A hospital which meets all requirements in Chapter 5, §20 of this manual is also a qualified hospital for purposes of beginning a benefit period when it furnishes the patient covered inpatient emergency services. Thus, generally, the benefit period begins when covered inpatient services are initially furnished to an entitled individual. However, the noncovered services furnished by a nonparticipating provider can begin a spell of illness only if the provider is a qualified provider. A qualified provider is a hospital (including a psychiatric hospital) or a SNF which meets all requirements in the definition of such an institution even though it may not be participating. A qualified hospital in Canada or Mexico is also a qualified provider for purposes of beginning a benefit period when it furnishes covered inpatient hospital services. If a person is in a nonqualified institution and is subsequently transferred to a qualified hospital (general or psychiatric), his/her benefit period begins on admission to the qualified hospital. Admission to a qualified SNF or to the SNF level of care in a swing-bed hospital begins a benefit period even though payment for the services cannot be made because the prior hospitalization or thirty-day transfer requirement has not been met. It is also worth noting that the SNF benefit’s “thirty-day” transfer requirement has a medical appropriateness exception (described in Pub. 100-02, Medicare Benefit Policy Manual, chapter 8, section 20.2.2), under which the allowable interval between a beneficiary’s discharge from a qualifying prior hospitalization and the initiation of SNF care can exceed the normal 30-day timeframe; moreover, in a situation where the allowable interval under this exception is 60 days or longer, the subsequent commencement of extended care services in the SNF would serve to trigger the start of a new benefit period. Inpatient care in a Religious Non-Medical Health Care Institution (whether as hospital or extended care services) can begin or prolong a benefit period. 10.4.2 - Ending a Benefit Period (Rev. 80, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)
The benefit period ends with the close of a period of 60 consecutive days during which the patient was neither an inpatient of a hospital nor of a SNF. To determine the 60 consecutive day period, begin counting with the day the individual was discharged. (See §10.4.3.2 of this chapter for determining the end of a benefit period when an individual remains in a SNF.) As noted in section 10.4, the term “benefit period” is synonymous with spell of illness. However, the statutory language (at §1861(a) of the Social Security Act) that describes a benefit period as a “spell of illness” is sometimes misunderstood to mean that a benefit period is linked to a particular medical episode or type of condition, so that the onset of a new and entirely unrelated condition could serve to end a benefit period even in the absence of a 60-day break in the beneficiary’s “inpatient” status. In fact, the onset of a new condition is not, in itself, relevant to the ending of a benefit period, which can occur only through a 60-day break in inpatient status, as described above. 10.4.3 - Definition of Hospital or SNF for Ending a Benefit Period (Rev.10880, Issued: 08-06-21, Effective: 11-08- 21, Implementation: 11-08-21) It is important to note that a benefit period cannot end while a beneficiary is an inpatient (see §10.4.4) of an institution that meets the basic definition of a “hospital” at §1861(e)(1) of the Social Security Act (the Act), even if the hospital does not meet all of the additional requirements that are necessary for starting a benefit period, as discussed further in §10.4.3.1 below (see also §1861(e) following (9) of the Act and the regulations at 42 CFR 409.60(b)(1)). Similarly, a benefit period cannot end while a beneficiary is an inpatient (see §10.4.4) of an institution that meets the basic definition of a “SNF” at §1819(a)(1) of the Act, as discussed further in §10.4.3.2 below. As noted in §2164 of the State Operations Manual (Pub. 100-07), Chapter 2, all hospitals and SNFs that are Medicare-certified are automatically considered to meet the applicable basic definition in this context by reason of the Medicare certification itself. Moreover, even an institution (or portion of an institution) that is not certified for Medicare can serve to prolong an inpatient’s benefit period if it meets either the basic “hospital” or “SNF” definition discussed above. 10.4.3.1 - Hospital Stay and End of Benefit Period (Rev. 1, 09-11-02) In order to end a benefit period, for at least 60 consecutive days, a beneficiary cannot have been in a hospital which meets the initial requirement in the definitions in Chapter 5, §20.1 through §20.7 of this publication. That is, the beneficiary cannot have been in a facility that is primarily engaged in providing, by or under the supervision of a physician(s), to inpatients: • Diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons or rehabilitation services for injured, disabled, or sick persons; or
• Psychiatric services for the diagnosis and treatment of mentally ill persons. A stay in a hospital outside the United States prolongs a benefit period. It may be assumed, in the absence of evidence to the contrary, that: • A foreign hospital in which a beneficiary spent one or more days meets the requirement of the definition in Chapter 5, §20 of this manual; and • The beneficiary's statement about length and place of stay is correct. 10.4.3.2 - SNF Stay and End of Benefit Period (Rev.10880, Issued: 08-06-21, Effective: 11-08- 21, Implementation: 11-08-21 Similarly, to end a benefit period, a beneficiary cannot have been an inpatient (see §10.4.4) of a SNF for at least 60 consecutive days; where SNF is defined in accordance with §§1861(a)(2) and 1819(a)(1) of the Social Security Act as a facility which is primarily engaged in providing skilled nursing care and related services to residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. As indicated above in §10.4.3, all Medicare-certified SNFs (including Medicare-certified distinct part SNFs) are automatically considered to meet this basic “SNF” definition by reason of the Medicare certification itself. See §2166 of the State Operations Manual (Pub. 100-07), Chapter 2, for the administrative criteria used in determining whether the basic “SNF” definition is met by a nursing home that is not Medicare-certified (including the noncertified portion of an institution that also contains a Medicare-certified distinct part SNF). Examples: An individual may be discharged from and readmitted to a hospital or SNF several times during a benefit period and still be in the same benefit period if 60 consecutive days have not elapsed between discharge and readmission. The stays need not be for related physical or mental conditions. Example 1: X was born 8/9/1936. On 7/28/2001, X entered a participating general hospital. After he/she had been in the hospital for 2 weeks, X was discharged on 8/11/2001. On his/her doctor’s orders, X entered a participating SNF on 8/15/2001, and remained an inpatient there (see §10.4.4) until his/her discharge on 10/27/2001. He/she had no further inpatient stays in 2001. X’s benefit period began on 8/1/2001, the first day of the month he/she attained age 65 and was entitled to hospital insurance. The benefit period ended 12/25/2001, the end of the 60-day period beginning with the date of his/her last discharge. Example 2: Y, over age 65, entered a participating general hospital on 8/28/2000 for treatment of a heart condition. He/she was discharged on 9/11/2000. On 10/3/2000, Y entered a Medicaid-only nursing facility, and remained an inpatient of this facility (see §10.4.4) until his/her discharge on 11/17/2000. On 12/26/2000, Y was again admitted to a
participating hospital because of injuries suffered in an accident. He/she was discharged on 1/13/2001 and had no further inpatient stays in 2001. Y’s benefit period began on 8/28/2000. His/her stay in the nursing facility began less than 60 days after his/her hospital stay and the benefit period was continued because he/she remained an inpatient there (see §10.4.4) even though Medicare did not cover the stay. The subsequent hospital stay began less than 60 days after the nursing facility stay and continued the benefit period although the condition treated was unrelated to his/her prior stays. The benefit period ended on 3/14/2001, the end of the 60-day period beginning with the day of last discharge. Example 3: Z, over age 65 and entitled to hospital insurance benefits, was admitted to General Hospital on 8/l/2000 and discharged on 8/10/2000, having received nonemergency hospital services. General Hospital met all the requirements in the definition of a hospital except those concerning utilization review and health and safety. While General Hospital met the minimum requirements of an emergency hospital, Z’s benefit period did not begin with his/her admission to this hospital because: 1. The hospital did not meet all of the requirements in the definition of a hospital; and 2. Although the hospital satisfied the minimum requirements for coverage of emergency services, Z did not receive emergency inpatient care there. (As noted previously, a stay in an emergency hospital does not begin a benefit period unless it actually involves the receipt of covered inpatient emergency services; by contrast, even a nonemergency stay in such a hospital can serve as a qualifying hospital stay for purposes of coverage under the posthospital extended care benefit.) Z was admitted to Haven Convalescent Home on 8/20/2000 and remained an inpatient of the home (see §10.4.4) until his/her discharge on 3/1/2001. He/she had no further inpatient stays in 2001. Haven Convalescent Home became a participating SNF on 1/1/2001. Z's benefit period began 1/1/2001, the day Haven Convalescent Home was determined to be a qualified SNF. The services Z received from that date through discharge were extended care services even though they were not covered and, therefore, not charged against Z’s Medicare SNF utilization. (The services were not covered posthospital extended care services because Z was not admitted to a participating SNF within 30 days after discharge from the hospital.) Z’s benefit period ended 4/29/2001, the end of the 60- day period beginning with the date of his discharge from the convalescent home. 10.4.4 - Definition of Inpatient for Ending a Benefit Period (Rev. 80, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13) Generally, a beneficiary is an inpatient of a hospital if the beneficiary is receiving inpatient services in the hospital (i.e., not on an outpatient basis). The type of care actually received is not relevant.
However, a different definition of inpatient applies in determining the end of a benefit period for a beneficiary in a SNF, under which such a beneficiary is considered an inpatient in this context only if the beneficiary's care in the SNF meets certain skilled level of care standards. Specifically, the beneficiary must need and receive a skilled level of care while in the SNF. This means that in order to have been an “inpatient” for benefit period purposes while in a SNF, the beneficiary must have required and received skilled services on a daily basis which could, as a practical matter, only have been provided in a SNF on an inpatient basis. (Under the regulations at 42 CFR 409.60(b)(2), an additional level of care criterion at 42 CFR 409.31(b)(2)--requiring that the SNF care must in some way relate back to a condition that was present during the beneficiary’s qualifying hospital stay--does not apply to benefit period determinations.) If these provisions were not met during the prior SNF stay, the beneficiary was not an inpatient of the SNF for purposes of prolonging the benefit period. Conversely, a beneficiary would remain an SNF “inpatient” in this context (thus prolonging his or her current benefit period) for as long as the beneficiary continues receiving a skilled level of care in the SNF--even if Part A payment has ended due to the beneficiary’s exhaustion of SNF benefits. Use the following presumptions for determining whether the skilled level of care standards were met during a prior SNF stay. Presumption 1: A beneficiary's care in a SNF met the skilled level of care standards if a Medicare SNF claim was paid for the care, unless such payment was made under limitation on liability rules. Presumption 2: A beneficiary's care in a SNF met the skilled level of care standards if a SNF claim was paid for the services provided in the SNF under the special Medicare limitation on liability rules pursuant to placement in a non-certified bed. Presumption 3: A beneficiary's care in a SNF did not meet the skilled level of care standards if a claim was paid for the services provided in the SNF pursuant to the general Medicare limitation on liability rules. (This presumption does not apply to placement in a non-certified bed. For claims paid under these special provisions, see Presumption 2.) Presumption 4: A beneficiary's care in a Medicaid nursing facility (NF) did not meet the skilled level of care standards if a Medicaid claim for the services provided in the NF was denied on the grounds that the services received were not at the NF level of care (even if paid under applicable Medicaid administratively necessary days provisions which result in payment for care not meeting the NF level of care requirements). Presumption 5: A beneficiary's care in a SNF met the skilled level of care standards if a Medicare SNF claim for the services provided in the SNF was denied on grounds other than that the services were not at the skilled level of care.
Presumption 6: A beneficiary's care in a SNF did not meet the skilled level of care standards if a Medicare claim for the services provided in the SNF was denied on the grounds that the services were not at the skilled level of care and no limitation of liability payment was made. Presumption 7: A beneficiary's care in a SNF did not meet the skilled level of care standards if no Medicare or Medicaid claim was submitted by the SNF. Presumptions 1 through 4 cannot be rebutted. Thus, prior Medicare and Medicaid claim determinations that necessarily required a level of care determination for the time period under consideration are binding for purposes of a later benefit period calculation. Presumptions 5 through 7 can be rebutted by the beneficiary showing that the level of care needed or received is other than that which the presumption dictates. Presumption 6 can be rebutted because the Medicare skilled level of care definition for coverage purposes is broader than the skilled level of care definition used here for benefit period determinations. Specifically, the requirement referred to in Chapter 4, §40.2 regarding prior hospital care related to the SNF care is included in the Medicare SNF coverage requirements but is not included in the standard for benefit period determinations. Therefore, Medicare payment could have been denied for a SNF stay on level of care grounds (i.e., not even waiver payment was made) because of noncompliance with that requirement, even though skilled level of care requirements for benefit period determinations were in fact met by the SNF stay. Consequently, when Medicare SNF payment is denied on level of care grounds, the beneficiary must be given the opportunity to demonstrate that he/she still needed and received a skilled level of care for purposes of benefit period determinations. NOTE: Effective October 1, 1990, the levels of care that were previously covered separately under the Medicaid SNF and intermediate care facility (ICF) benefits are combined in a single Medicaid nursing facility (NF) benefit. Thus, the Medicaid NF benefit includes essentially the same type of skilled care covered by Medicare's SNF benefit, but it includes less intensive care as well. This means that when a person is found not to require at least a Medicaid NF level of care (as under Presumption 4), it can be presumed that he or she also does not meet the Medicare skilled level of care standards. However, since the NF benefit can include care that is less intensive than Medicare SNF care, merely establishing that a person does require NF level care does not necessarily mean that he or she also meets the Medicare skilled level of care standards. Determining whether an individual who requires NF level care also meets the Medicare skilled level of care standards requires an actual examination of the medical evidence and cannot be accomplished through the simple use of a presumption. Therefore, the previous references to Medicaid claims have been deleted from those presumptions which establish that an individual does meet the Medicare standards. Medicare no-payment bills submitted by a SNF result in Medicare program payment determinations (i.e., denials). Therefore, such no-payment bills trigger the appropriate
presumptions. This also applies in any State where the Medicaid program utilizes no- payment bills which lead to Medicaid program payment determinations. If a SNF erroneously fails to submit a Medicare claim (albeit a no-pay claim) when Medicare rules require such submission, A/B MACs (A) request a SNF to submit one. Once the no-pay bill is submitted and denied, the applicable presumption (other than presumption 7) is triggered. If a patient is moving from a SNF level of care to a non-SNF level of care in a facility certified to provide SNF care, occurrence code 22 (date active care ended) is used to signify the beginning of the no-pay period on the bill and trigger the appropriate presumptions. Where the presumptions are rebuttable (i.e., 5 through 7), rebuttal showings are permitted at both A/B MAC (A) determination levels under 42 CFR 405, Subpart G (i.e., a rebuttal showing regarding the status of a prior SNF stay is made at the time that an inpatient claim is submitted and/or at the reconsideration level). A/B MACs (A) evaluate rebuttal documentation even if the presumption being rebutted was triggered by a Medicaid denial. This special rule for determining whether a beneficiary in a SNF is an inpatient for benefit period purposes is applicable in all cases where a prior SNF stay affects benefit period status, not only when a beneficiary is in exhausted or copay status and is seeking to renew a benefit period. The rule has equal application where it results in the beneficiary starting a new benefit period and paying a new deductible without receiving an increase in the amount of Medicare benefits paid. 20 - Supplementary Medical Insurance (SMI) (Part B) (Rev. 1, 09-11-02) Supplementary Medical Insurance is described in the following subsections. 20.1 - Supplementary Medical Insurance Incurred Expenses (Rev. 1, 09-11-02) The SMI plan includes coverage for expenses incurred for the services described in Chapter 1, §10.3: Payment may not be made under Part B for services furnished an individual entitled to have payment made for those services under Part A, e.g., if the expenses incurred were to satisfy a Part A deductible or coinsurance amount, or if payment would be made under Part A except for the lack of request for payment or physician certification. 20.2 - Part B Annual Deductible (Rev. 12980; Issued:11-25-24; Effective: 01-01-25; Implementation: 01-06-25) In each calendar year, a cash deductible must be satisfied before payment can be made under SMI. (See 20.4 of this chapter for exceptions.)
Calendar Year Deductible 1966 – 1972 $50 1973 – 1981 $60 1982 – 1990 $75 1991 – 2004 $100 2005 $110 2006 $124 2007 $131 2008 $135 2009 $135 2010 $155 2011 $162 2012 $140 2013 $147 2014 $147 2015 $147 2016 $166 2017 $183 2018 $183 2019 $185 2020 $198 2021 $203 2022 $233 2023 $226 2024 $240 2025 $257 Expenses count toward the deductible on the basis of incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non-covered expenses do not count toward the deductible. Even though an individual is not entitled to Part B benefits for the entire calendar year (i.e., insurance coverage begins after the first month of a year or the individual dies before the last month of the year), he or she is still subject to the full deductible for that year. Medical expenses incurred in the portion of the year preceding entitlement to medical insurance are not credited toward the deductible. The date of service generally determines when expenses were incurred, but expenses are allocated to the deductible in the order in which the bills are received. Services not subject to the deductible cannot be used to satisfy the deductible. Pro Rata Amounts Pro Rata Amounts First Month Second Month 2012 $100.20 $39.80
