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HealthCare News

January 9, 2018

Medicare Deductible, Coinsurance, Premium Rates and Therapy Cap Values for Calendar Year 2018

 

 Background

Beneficiaries who use covered Part A services may be subject to deductible and coinsurance requirements. A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount payable by the Medicare program to the hospital, for inpatient hospital services furnished in a spell of illness. When a beneficiary receives such services for more than 60 days during a spell of illness, he or she is responsible for a coinsurance amount equal to one-fourth of the inpatient hospital deductible per-day for the 61st - 90th day spent in the hospital. An individual has 60 lifetime reserve days of coverage, which they may elect to use after the 90th day in a spell of illness. The coinsurance amount for these days is equal to one-half of the inpatient hospital deductible. A beneficiary is responsible for a coinsurance amount equal to one-eighth of the inpatient hospital deductible per day for the 21st through the 100th day of Skilled Nursing Facility (SNF) services furnished during a spell of illness. 

Most individuals age 65 and older, and many disabled individuals under age 65, are insured for Health Insurance (HI) benefits without a premium payment. The Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly premium. Since 1994, voluntary enrollees may qualify for a reduced premium if they have 30 - 39 quarters of covered employment. When voluntary enrollment takes place more than 12 months after a person’s initial enrollment period, a 10 percent penalty is assessed for 2 years for every year they could have enrolled and failed to enroll in Part A.

Under Part B of the Supplementary Medical Insurance (SMI) program, all enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute. When Part B enrollment takes place more than 12 months after a person’s initial enrollment period, there is a permanent 10 percent increase in the premium for each year the beneficiary could have enrolled and failed to enroll.

 

 2018 PART A HOSPITAL INSURANCE (HI)

Deductible: $1,340.00 

Coinsurance: 

$335.00 a day for 61st - 90th day 

$670.00 a day for 91st - 150th day (lifetime reserve days)

$167.50 a day for 21st - 100th day (Skilled Nursing Facility coinsurance) 

Base Premium (BP): $422.00 a month 

BP with 10 percent surcharge: $464.20 a month 

• BP with 45 percent reduction: $232.00 a month (for those who have 30-39 quarters of coverage) 

• BP with 45 percent reduction and 10 percent surcharge: $255.20 a month 

 

2018 PART B - SUPPLEMENTARY MEDICAL INSURANCE (SMI) 

Standard Premium: $134.00 a month 

Deductible: $183.00 a year 

Pro Rata Data Amount: 

 $126.88 1st month 

 $56.12 2nd month

 • Coinsurance: 20 percent

For more information, please refer to MLN Matters Number: MM10405

 

Therapy Cap Values for Calendar Year (CY) 2018

 

The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) applies, per beneficiary, annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B, commonly referred to as “therapy caps.” The therapy caps are updated each year based on the Medicare Economic Index. 

For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010

For occupational therapy, the CY 2018 cap is $2,010.

 

For more information, please refer to MLN Matters Number: MM10341   

 

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