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Are There Limits on Medicare Coverage?

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.

Therapy services: Medicare limits the amount of coverage you can get as an outpatient for physical or occupational therapy and speech-language pathology in any given year. In 2014 the limits are $1,920 for occupational therapy and $1,920 for physical therapy and speech-language pathology combined. These dollar limits are the total cost of the services received in a year—including what Medicare pays, what you pay (20 percent of the Medicare-approved amount) and your Part B annual deductible ($147 in 2014) if this applies. Here are exceptions:

•  Medicare may continue to cover these services, beyond the annual limits, if you have a condition that requires ongoing therapy, such as extensive rehabilitation for stroke and heart disease. To get this exception, your therapist must justify the need when he or she bills Medicare.

• There are no limits on medically necessary therapy that you get at a hospital outpatient department or emergency room.

If your therapy exceeds the limits, and you don’t qualify for an exception, you can continue to get Medicare coverage if you’re able to switch to hospital outpatient or emergency services. Otherwise, you’re responsible for the full cost for the rest of the year.

For more information see Medicare’s guidance on therapy caps.

Note:  The idea that, as a result of the Affordable Care Act (aka “ObamaCare), Medicare will stop covering needed surgeries and other services for people over a certain age (such as 70) has been widely circulated in mass emails.  Don’t believe them. They’re not true. They’re intended to scare older Americans into believing that the ACA will ration their care.  (And you can easily check out their veracity by entering a key phrase from them into a search engine and reading how various fact-checking sites have refuted their claims.) Apart from the limitations listed above, Medicare covers services strictly on the basis of medical necessity—regardless of age. 

Patricia Barry is a senior editor for AARP Integrated Media and the author of “Medicare For Dummies” (Wiley/AARP, October 2013).