Q. Is there a cap on the amount of Medicare services you can use? I’ve had several expensive surgeries, and I’m worried that my benefits may run out.
A. In general, there’s no upper dollar limit on Medicare benefits. As long as you’re using medical services that Medicare covers—and provided that they're medically necessary—you can continue to use as many as you need, regardless of how much they cost, in any given year or over the rest of your lifetime.
However, some individual Medicare benefits do come with limits. These include:
Hospital lifetime reserve days: Medicare Part A covers a stay in the hospital for any single spell of illness or injury within a time frame of 90 days. This is known as a benefit period, and there’s no limit to the number of benefit periods you can have. But if you need to stay in the hospital for more than 90 days with the same illness or injury, you have the option of using some of your 60 lifetime reserve days. These allow you to extend your hospital stay for a higher copayment ($608 a day in 2014). You can use these days—one or more at a time, or as you need them—over the rest of your life. Once the 60 reserve days are exhausted, you would pay the hospital’s full daily charge (except for services covered under Medicare Part B, such as physician visits) if you need to stay in the hospital for more than 90 days in a benefit period. Here are some exceptions:
* You have the option not to use your lifetime reserve days for any particular extended hospital stay—for example, if you prefer to store them up for a rainy day, or if the hospital’s daily rate is the same as or less than the Medicare copay.
* All standard medigap supplementary policies cover an additional 365 lifetime reserve days, after Medicare’s reserve days are used up.
* All standard medigap policies pay the copays for lifetime reserve days.
* If you’re enrolled in Medicaid (state medical assistance for people with limited incomes), it usually covers the copays for lifetime reserve days.
For more information, see “Ask Ms. Medicare: What is a Hospital Benefit Period?”
Psychiatric hospital stays: Medicare covers only 190 days of inpatient care in a psychiatric hospital in your lifetime. A psychiatric hospital is defined as a facility that provides care only for patients with mental health conditions. There’s no lifetime limit for mental health treatment you receive as an inpatient in a general hospital. Medicare’s 60 lifetime reserve days, as explained above, cannot be used to extend the 190-day limit for stays in psychiatric hospitals, but can be used for inpatient mental health treatment in general hospitals.
For more information, see the official publication “Medicare & Your Mental Health Benefits”.
Skilled nursing facility (SNF) benefit: This benefit is available if you need continuing skilled nursing care after you’ve been in the hospital for at least three days, under certain conditions, but it comes with limits. Medicare pays the full cost for up to 20 days; from day 21 through day 100, you pay a share of the cost ($152 a day in 2014); beyond 100 days, you pay the full cost. Some or all of these costs may be covered if you have additional insurance coverage through Medicaid, employer health insurance, long-term care insurance or medigap supplementary insurance—check your policy to find out.
For more information, see Medicare’s explanation of Medicare coverage for care in skilled nursing facilities.