B. Determining days available

The patient will be eligible to have payment made for inpatient psychiatric hospital services and inpatient hospital services primarily for the diagnosis or treatment of mental illness in the first benefit period only for the number of days remaining after the reduction is applied. To determine the number of days available in the first benefit period to pay for inpatient psychiatric hospital services and inpatient hospital services for the treatment of mental illness, take the following steps:

1. determine how many days in the 150 day preentitlement period the patient spent in a psychiatric hospital

2. subtract these from 150. Payment is made for the remaining days in the following order of priority: a. the 60 full benefit days, b. the 30 coinsurance days at one quarter the inpatient hospital deductible, c. the 60 lifetime reserve days at one half the inpatient hospital deductible.

Benefit days, including lifetime days, not available to the patient because of the psychiatric limitation nevertheless remain available for use in hospitalization not subject to the reduction: a general hospital stay for a nonpsychiatric condition or a tuberculosis hospital stay. The lifetime days not previously used also remain available for any inpatient stays (including psychiatric hospital stays) in subsequent benefit periods.

Example 1:

James Powers was an inpatient of a participating psychiatric hospital on their first day of entitlement on February 1, 1981. James had been in such a hospital in the preentitlement period for 20 days. Therefore, 130 days are payable. Payment would be made in the following order: 60 full benefit days; 30 $51 coinsurance days; 40 $102 coinsurance (lifetime) days.

Example 2:

The same facts as example 1, except that Mr. Powers had been in a psychiatric hospital in the preentitlement period for 70 days. Therefore, 80 days are payable. Payment would be made in the following order: 60 full benefit days; 20 $51 coinsurance days.

Example 3:

The same facts as in example 1, except that Mr. Powers had been in a psychiatric hospital in the preentitlement period for 110 days. Therefore, 40 days are payable. Payment would be made for these 40 days at full benefit.