SSR 76-16: Section 1861(a) and (b)—Hospital Insurance Benefits—Duration of Spell of Illness—Inpatient Hospital Services
20 CFR 405.220
This ruling supersedes SSR 70-25 (with the exception of the penultimate paragraph, this ruling is a reprint of SSR 70-25).
A hospital insurance beneficiary with several periods of hospitalization beginning March 13, had been discharged from the hospital on May 3 and was readmitted for treatment of the same condition on July 24. In the interim, on June 27, she reported to the hospital's outpatient clinic for treatment of an unrelated condition, but because of the doctor's delay, she was admitted to the hospital and was furnished 1 day of inpatient hospital care. Held, since she did not remain out of the hospital for a period of 60 consecutive days between her discharge on May 3 and the admission of July 24 as required by section 1861(a) of the Social Security Act, her readmission to the hospital on July 24 did not start a new spell of illness but was a continuation of the original spell of illness which began on March 13.
Section 1812(a) of the Social Security Act defining the scope of hospital insurance benefits, provides that an individual entitled to such benefits is eligible to have payment made on his behalf for up to 150 days  of inpatient hospital services during any spell of illness, defined as follows in section 1861(a) of the Act:
* * * a period of consecutive days—(1) beginning with the first day (not included in a previous spell of illness) (A) on which such individual is furnished inpatient hospital services or extended care services, and (B) which occurs in a month for which he is entitled to benefits under Part A, and
(2) ending with the close of the first period of 60 consecutive days thereafter on each of which he is neither an inpatient of a hospital nor an inpatient of an extended care facility.
R, a hospital insurance beneficiary, had several periods of hospitalization beginning in March 1969, as follows: March 13 through April 3, a period of 21 days; April 7 through May 3, 26 days; July 24 through August 23, 30 days. Between her discharge from the hospital in May and her readmission in July, R had to report to the outpatient department of the hospital to have a small growth removed. Because of unavoidable delay, the doctor could not attend to this matter on the day R reported, and advised her to stay overnight in the hospital, the night of June 27-28.
R's hospital bill contained a charge of $198, representing the coinsurance amount of $11 for each day beginning August 5, which was the 61st day of inpatient hospital services used by R in the spell of illness which had begun when she was first admitted to the hospital on March 13, 1969, according to the hospital's records.  R has protested the coinsurance charge, stating that her current spell of illness (benefit period) had actually begun on July 24, when she was readmitted to the hospital for a month's stay, and that no coinsurance amount was therefore due. The basis for this protest was that she did not consider the overnight stay in the hospital as inpatient care, and therefore, it should not interrupt the out-of-hospital period of more than 60 days from her discharge on May 3 to her readmission on July 24.
The issue to be resolved here is whether a new spell of illness, as defined in section 1861(a) supra, began on July 24, 1969, with R's readmission to the hospital, or whether such readmission occurred within the initial spell of illness begun on March 13, 1969, so as to make R liable for payment of the coinsurance amount of $198 for which she was billed. This in turn depends on whether or not R was furnished services as an inpatient of the hospital on June 27.
Section 1861(b) of the Act provides, as pertinent here, that the term "inpatient hospital services" means the following items and services furnished to an inpatient of a hospital . . . by the hospital—
(1) bed and board;
(2) such nursing services and other related services, such use of hospital facilities, and such medical social services as are ordinarily furnished by the hospital for the care and treatment of inpatients, and such drugs, biologicals, supplies, appliances, and equipment, for use in the hospital, as are ordinarily furnished by such hospital. . . .
* * * * *
(4) medical or surgical services provided by a physician, resident, or intern; and
(5) the services of a private-duty nurse or other private-duty attendant.
* * * * *
The file contains the following statement from R's physician:
During the interval between her dismissal of May 3, and her readmission on July 24, she developed a small growth on the neck, and was advised to have it removed in the outpatient department (6/27) of [S] Hospital. Due to unavoidable delays on my part it was quite late before I was able to attend to the removal of this growth, and for this reason I advised her to remain in the hospital overnight. There was nothing in her condition which would have necessitated her remaining in the hospital. This overnight stay was strictly on the basis of the lateness of the hour.
The evidence in this case, which is not in dispute, also shows that R was in fact admitted to the hospital for the one day in question. While it is true that the physician stated that the services rendered were originally scheduled to be performed in the hospital's outpatient department and that R's admission to the hospital for an overnight stay was due to the lateness of the hour, R was in fact admitted to the hospital and received one day inpatient hospital care. The fact that the inpatient services received were either covered or excluded from coverage is irrelevant in the determination of whether or not they would serve to extend the spell of illness. It is only relevant that the beneficiary was admitted as an inpatient.
Since R's stay in the hospital beginning June 27 was as an inpatient receiving inpatient hospital services, it is held that a new spell of illness did not begin with her readmission to the hospital on July 24, since there had not elapsed a period of 60 consecutive days in the initial spell of illness (which began March 13) on each of which she was not an inpatient of a hospital, as required by section 1861(a) of the Social Security Act. Held further, since only one spell of illness is involved, beginning March 13, R is responsible for payment of the coinsurance amount of $198 for which the hospital billed her, representing $11 for each day beginning with the 61st day of inpatient hospital services used by R in that benefit period.
 The beneficiary has 90 days coverage for inpatient hospital services in any spell of illness (benefit period); he also has a "lifetime reserve" of 60 additional days of inpatient hospital services on which he may draw after he has exhausted 90 days in a benefit period (unless he specifically elects not to use them).
 Under section 1813 of the Act, a hospital beneficiary is responsible for payment of a coinsurance amount for each day of inpatient hospital services used from the 61st through the 90th day during any spell of illness (benefit period). With respect to a spell of illness beginning in 1969, any payment made under the program on behalf of a hospital insurance beneficiary is subject to reduction as follows: a deductible of $44, a coinsurance amount of $11 for each day from the 61st through the 90th day of covered inpatient hospital services used, and a coinsurance amount of $22 for each reserve day used from the 91st through the 150th day during that spell of illness.