1. Total number of days that an insurance company will pay within a benefit period. 2. Under the Medicare program, the number of days that a beneficiary is entitled to receive payment for covered services with the exception of lifetime reserve days. Also see lifetime reserve .

Medicare phrase that refers to the date on which the beneficiary has used the maximum benefits for a current benefit period. This applies when a patient refuses to use or has used all of his or her lifetime reserve days. Under the Medicare program, a reserve of 60 days of inpatient hospital care is available over an individual’s lifetime beyond the normal limit. Also see lifetime reserve .

Method for establishing the amount of benefit payable under each contingency (unforeseen event) covered by a group insurance contract. The formula includes salary and job or years of employment at the time the benefit is paid.

1. Limit of benefits an individual is entitled to receive depending on the insurance policy. 2. In workers’ compensation cases, benefit levels for an injured employee are set by state laws.

Insurance provision that restricts coverage regardless of medical necessity. Benefit limitations may be found in the explanation of coverage section of the insurance policy or in a booklet supplied by the insurance company. Also known as benefit booklet, benefit plan summary, summary plan description ; also see explanation of coverage (EOC) .

Highest dollar amount that an insurance company or managed care plan will pay for specified health care services. A benefit can be expressed either as a length of time (e.g., 60 days of semiprivate hospital room charges) or as a dollar amount (e.g., $1500 for a certain procedure).