Medicare terms

Learn more about Medicare. Start with these definitions.

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lifetime reserve days

If you need to remain hospitalized for more than 90 days in a single benefit period, Original Medicare will cover a portion of your costs for a total of 60 additional reserve days over the course of your lifetime. For each of these 60 lifetime reserve days, you pay coinsurance ($670 per day, in 2018), and Medicare pays the rest of the covered hospital costs.

Medicare inpatient coverage is based on how long you’re hospitalized. When you’re first admitted as an inpatient at the start of your benefit period, you pay your deductible ($1,340 in 2018), and then Medicare pays for your hospital care for 60 days, without you having to pay anything else for inpatient care.

If you’re still hospitalized after 60 days, you’ll start paying a portion of the bill, for the next 30 days. In 2018, you’ll pay $335 for each day in the hospital from day 61 to day 90.

If you’re still hospitalized after 90 days, you’ll either have to start paying the full bill yourself, or dipping in to your lifetime reserve days. If you use lifetime reserve days, you pay $670 per day (in 2018) and Medicare pays the rest. If you’re ultimately discharged from the hospital after 100 days, you will have used up 10 of your lifetime reserve days. That means you’ll have 50 remaining, which you could use in the future if you ever have another hospitalization that lasts more than 90 days.

If you buy a Medigap policy, you’ll have an extra 365 days of inpatient coverage, after your Medicare lifetime reserve days are used up.

Alternatively, Medicare Advantage plans have built-in caps on out-of-pocket costs, which can’t exceed $6,700 (not counting prescription drug costs) in 2018. So with a Medicare Advantage plan, it doesn’t matter how many days you’re hospitalized — you won’t have to pay more than the plan’s out-of-pocket limit for your hospitalization (note that Medicare Advantage plans have drawbacks too, such as limited provider networks. This article will help you figure out whether you’d be better off with Medicare Advantage or Original Medicare).

limiting charge

When you receive care from a health care service provider who doesn’t accept Medicare for your treatment but hasn’t entirely opted out of Medicare, the most you can be charged, under federal law, is 15 percent over the amount that Medicare will pay the doctor for that service (in addition to your normal Medicare out-of-pocket costs). And non-participating providers are paid a little less by Medicare — 95 percent of the normal reimbursement amount — so the additional 15 percent charge is based on that amount, rather than the normal reimbursement amount.

This cap on how much you can be charged is called the limiting charge. Limiting charges do not apply to equipment or medical supplies.

Most doctors do accept Medicare’s payment as payment in full (ie, they are participating providers), which means that the limiting charge doesn’t apply to them. Instead, you’ll just pay your normal Medicare deductible and coinsurance, and the doctor will not be able to bill you for any additional amount above and beyond what Medicare pays.

The limiting charge does not apply to providers who have opted out of Medicare altogether. In that case, the patient is responsible for the entire bill, and there’s no limit on how much the provider can charge. Very few doctors — an estimated 1 percent nationwide — have opted out of Medicare, but among some specialties the opt-out rate is much higher: 42 percent of psychiatrists have opted out of Medicare.

long-term care

Long-term care generally refers to non-medical care (ie, custodial care) for patients who need assistance with basic daily activities such as dressing, bathing and using the bathroom. Long-term care may be provided at home or in facilities that include nursing homes and assisted living.

Medicare, generally, does not pay for custodial long-term care, whether it’s in a nursing home or provided in-home. Medicare will pay for medical care provided in addition to long-term care (for example, if a nursing home resident suffers a heart attack, Medicare will pay for the treatment necessary for the heart attack, despite the fact that Medicare is not paying the monthly nursing home bill).

And Medicare will also pay for physical therapy, occupational therapy, or other medical care received in a skilled nursing facility, provided the patient meets certain criteria (including at least a three-day stay as a hospital inpatient prior to the stay in the skilled nursing facility).

Medicaid, which is a separate program for low-income Americans, administered jointly by the states and the federal government, does cover long-term care for people who have exhausted their resources. Nearly two-thirds of nursing home residents in the US have Medicaid coverage. Seniors who qualify for both Medicaid and Medicare are called dual-eligible.