Medicare Beneficiary Law and Legal Definition

Medicare beneficiary means an individual who is entitled to benefits under medicare part A plan and enrolled under medicare part B plan or enrolled in both medicare part A and part B plan and who resides in the U.S. Medicare beneficiaries pay deductibles and 20 percent coinsurance for most services and equipment. When a health services provider bills medicare, it agrees to accept the amount that medicare will pay, and that once medicare is billed a medicare beneficiary will not be charged either directly or indirectly for items or services that the beneficiary is entitled to have paid.

A Medicare beneficiary is entitled to 90 days of Part A coverage for inpatient hospital services for each spell of illness, 42 U.S.C.S. § 1395d [a] [1], which is referred to in the Medicare regulations as a benefit period. 42 CFR 409.61. A spell of illness or benefit period begins on the first day of admission to the hospital and ends on the 60th consecutive day after the beneficiary is no longer an inpatient in the hospital or a skilled nursing facility or receiving home health care or hospice services. 42 U.S.C.S. § 1395x [a]; 42 C.F.R. § 409.60 [b] [1]. Whenever admitted to a hospital for a new spell of illness or benefit period, a beneficiary is entitled to another 90 days of Part A coverage. In addition, each Medicare beneficiary has a lifetime reserve of 60 days that the beneficiary may elect to use toward one or more hospital stays. 42 C.F.R. § 409.61 [a] [2]. However, if the beneficiary has elected to apply the 60 reserve days to a previous hospital stay, the lifetime reserve is exhausted. [Sisters of Charity Hosp. v. Riley, 231 A.D.2d 272 (N.Y. App. Div. 1997)]