C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 409—HOSPITAL INSURANCE BENEFITS › Subpart G—Hospital Insurance Deductibles and Coinsurance

42 C.F.R. § 409.80

Inpatient deductible and coinsurance: General provisions

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(a) What they are. (1) The inpatient deductible and coinsurance amounts are portions of the cost of covered hospital or CAH or SNF services that Medicare does not pay.

(2) The hospital or CAH or SNF may charge these amounts to the beneficiary or someone on his or her behalf.

(b) Changes in the inpatient deductible and coinsurance amounts. (1) The law requires the Secretary to adjust the inpatient hospital deductible each year to reflect changes in the average cost of hospital care. In adjusting the deductible, the Secretary must use a formula specified in section 1813(b)(2) of the Act. Under that formula, the inpatient hospital deductible is increased each year by about the same percentage as the increase in the average Medicare daily hospital costs. The result of the deductible increase is that the beneficiary continues to pay about the same proportion of the hospital bill.

(2) Since the coinsurance amounts are, by statute, specific fractions of the deductible, they change when the deductible changes.

[48 FR 12541, Mar. 25, 1983, as amended at 58 FR 30666, May 26, 1993]
Notes of Decisions
Cited in 3 cases, 2007–2015 · leading case: Grossmont Hosp. Corp. v. Sylvia Mathews Burwell, 797 F.3d 1079 (D.C. Cir. 2015).
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Grossmont Hosp. Corp. v. Sylvia Mathews Burwell, 797 F.3d 1079 (D.C. Cir. 2015). “§ 1395e; 42 C.F.R. § 409.80 et seq. Generally, the remaining costs are reimbursed by the Medicare program to the hospital through fiscal intermediaries, which are typically private insurance companies.”
Lakeland Reg'l Health Sys. v. Sebelius, 958 F. Supp. 2d 1 (D.D.C. 2013). “42 C.F.R. §§ 409.80 — .83. In order to prevent shifting the costs of covered services to non-Medicare patients, the Medicare program reimburses hospitals when they are unable to collect coinsurance and deductible payments from Medicare beneficiaries.”
Battle Creek Health Sys. v. Leavitt (6th Cir. 2007). “42 C.F.R. §§ 409.80 - 409.83. Before 1983, the Medicare Act based hospital reimbursement upon a retrospective determination of “reasonable cost” as defined in the Secretary’s regulations and identified in a provider’s annual cost report.”
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