Medicare Additional Information – Terms/Definitions/Explanations
Return to Navigating Medicare main page.
Centers for Medicare & Medicaid Services Glossary of Terms
This glossary explains terms found on the cms.hhs.gov web site, but it is not a legal document.
Disclaimer: for specific details about Medicare,
- contact Medicare direct (Medicare.gov or 1-800-633-4227 (1-800-MEDICARE))
- or contact the Social Security Administration (https://www.ssa.gov/benefits/medicare/ or 1-800-772-1213).
- You can also make an appointment to visit your local Social Security office. (Call first to make an appointment.) You can find the local Social Security office here. Most, if not all, Social Security offices are now open to the public. You should be aware that the offices are very busy and appointments should be made before visiting an office. Even with an appointment there could be long wait times.(No longer applicable: On March 17, 2020, Social Security suspended face-to-face service to the public in field offices and hearings offices nationwide until further notice. However, critical services are still provided via phone, fax and online. You can use the local office lookup to obtain additional phone numbers).
Any information at SeniorViewsUSA is to ease the process but is not the final say in how the process works.
Benefit period is the way that Medicare measures your use of a general hospital and skilled nursing facility (SNF) services. It is not tied to a calendar year.
A Benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility. The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care in a skilled nursing facility) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.
For admissions to general hospitals, Medicare pays a graduated amount from 1 to 90 days (of which the Medicare beneficiary will pay a coinsurance for days 61-90, $419 in 2025 ($408 in 2024, $400 in 2023, $389 in 2022, $371.00 in 2021, $352 in 2020, $341 in 2019). Then from over 90 days the beneficiary will pay an $838 coinsurance in 2025 up to the 60 lifetime reserve days. After that, the beneficiary will pay the entire fees, unless covered by a separate private insurance. Standard Medigap (Medicare Supplement) policies cover the coinsurance for lifetime reserve days. Standard Medigap (Medicare Supplement) policies cover an additional 365 lifetime reserve days after Medicare benefits are used up.
For admissions to skilled nursing facilities, Medicare pays all up to 20 days at a skilled nursing facility. The beneficiary pays a $209.50 coinsurance daily for days 21 to 100 days. For a skilled nursing facility the beneficiary will pay all costs after 100 days.
Copayment –
A copayment refers to a flat amount that you are required to pay for a particular medical service (such as a visit to the doctor) or prescription drug. Some plans require different copayments depending on the services received, which means you pay different flat amounts for different medical services and/or prescription drugs. For example, a Medicare Advantage plan may charge a $20 copayment for a primary care doctor and a $50 copayment for a specialist or with a Medicare Part D (drug prescription plan) you may pay a $10 copayment for one tier of drugs.
Coinsurance –
Coinsurance is a percentage of a service, item, or medication that you must pay. This amount may vary depending on your specific plan. With this form of payment, each time you seek medical care, you would pay a percentage of your medical expenses out-of-pocket, either at the time of service/purchase or once the bill arrives. For example, if your bill is $100 and your coinsurance states that you must pay 10%, you would be responsible for paying $10.
Many plans have different coinsurance amounts for in-network versus out-of-network providers.
Hospital discharge planning check list –
For patients and their caregivers preparing to leave a hospital, nursing home, or other care setting.
Lifetime reserve days –
are the days that you can stay in a general hospital over the 90 days covered by Medicare Part A. For 2025, 2024, 2023, 2022, 2021 2020, 2019 and 2018 Medicare Part A allows for 60 lifetime reserve days. You do have to pay the coinsurance amount of $419 in 2025 for 61-90 days and $838.00 in 2025 for over 90 days ($816 in 2024, $800.00 in 2023 , $742 in 2021, $704.00/day in 2020, $682.00/day in 2019, $670.00/day in 2018). Standard Medigap (Medicare Supplement) policies cover the coinsurance for lifetime reserve days. Standard Medigap (Medicare Supplement) policies cover an additional 365 lifetime reserve days after Medicare benefits are used up.
General hospital vs Psychiatric Hospital – A psychiatric hospital is defined as a facility that provides care only for patients with mental health conditions. A General Hospital provides care for patients with any type of condition.
Benefit Period – Lifetime limit of 190 days in a psychiatric hospital. There’s no lifetime limit for mental health treatment you receive as an inpatient in a general hospital.
Lifetime reserve days – Cannot be used and are not applicable to Psychiatric Hospitals.
To be admitted to a skilled nursing facility and covered by Medicare Part A, you must have been admitted to a general hospital as an inpatient for 3 days. This means that if you are getting observation services, the day(s) under observation do not count towards inpatient status in a hospital.
There are additional conditions to qualify for skilled nursing facility benefits, and they come with limits.
Additional Medicare Skilled Nursing Facility information.
Medicare pays the full cost for up to 20 days; from day 21 through day 100, you pay a share of the cost ($209.50/day in 2025, $204.00 in 2024, $200.00 in 2023, $185.50 in 2021, $176.00/day in 2020, $170.50/day in 2019, $167.50/day in 2018); 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 (Medicare Supplement) insurance—check your policy to find out.
You may not need a 3-day minimum inpatient hospital stay if your doctor participates in an Accountable Care Organization or another type of Medicare initiative approved for a “Skilled Nursing Facility 3-Day Rule Waiver.”
Benefit Period – 60 days
Lifetime reserve days – Not applicable.
Therapy (physical/occupational/speech-language pathology) –
Medicare Part B (Medical Insurance) helps pay for medically necessary outpatient physical therapy, occupational therapy, and speech-language pathology services.
There are no limits on how much Medicare pays for medically necessary outpatient therapy services in one calendar year (also called “therapy caps” or “therapy cap limits”).
However, your therapist or therapy provider will need to provide additional information to the Medicare insurance claim to justify the therapy is reasonable and medically necessary if the dollar amount for the therapy exceeds a specified dollar amount, therapy threshold. The threshold dollar amount for Physical Therapy and Speech-Language services combined is $2,410 in 2025 ($2,330 in 2024, $2,230 in 2023, $2,110 in 2021, $2,080 in 2020, $2,040 in 2019) , and for Occupational Therapy services the threshold amount is $2,410 in 2025 ($2,330 in 2024, $2,230 in 2023, $2,110 in 2021, $2,080 in 2020, $2,040 in 2019) . There is also a targeted medical review (MR) process threshold amount of $3,000. For example, services exceeding $3,000 annually for Physical Therapy and Speech-Language Pathology Therapy services combined, or Occupational Therapy services may be subject to additional review.
Benefit Period – Calendar year.
The Medicare recipient will be responsible for 20% of the Medicare-approved amount and the Medicare Part B deductible applies. A Medicare Supplement (Medigap) plan may cover the deductible and 20% coinsurance.
This information only applies to those that have Original Medicare. If you have a Medicare Advantage plan, you need to check with you plan for information about your plan’s coverage rules on therapy services.
Centers for Medicare & Medicaid Services 2025 Therapy Services update.
Centers for Medicare & Medicaid Services 2024 Therapy Services update.
Centers for Medicare & Medicaid Services 2023 Therapy Services update.
Centers for Medicare & Medicaid Services 2022 Therapy Services update.
Centers for Medicare & Medicaid Services 2021 Therapy Services update.
Centers for Medicare & Medicaid Services 2020 Therapy Services update.
Return to Navigating Medicare main page.