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Medicare Part A - Hospital Insurance

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Medicare Part A - Hospital Insurance

Thursday, July 13, 2017 9:04 AM

Medicare Part A, often referred to as hospital insurance, is Medicare coverage for hospital care, skilled nursing facility care, hospice care, and home health services. It is usually available premium-free if you or your spouse paid Medicare taxes for a certain amount of time while you worked, if you receive or are eligible to receive Social Security or Railroad Retirement Board benefits, or if you or your spouse had Medicare-covered government employment.

If you do not qualify for premium-free Part A, you may choose to buy it. For instance, you may pay up to $413 per month in 2017 for Part A insurance.

What Does Medicare Part A Cover?

Part A helps covers the costs associated with:

  • Inpatient hospital stays
  • Stays at a skilled nursing facility, including medically necessary skilled nursing and rehabilitation care
  • Home health care
  • Psychiatric inpatient care
  • Hospice care

It’s important to note that Medicare does not cover care that is primarily custodial, such as assistance with bathing and eating.

Medicare Part A Coverage Is Based on Benefit Periods

How Are Benefit Periods Determined?

Original Medicare measures your coverage for hospital or skilled nursing care in terms of a benefit period. Beginning the day you are admitted into a hospital or skilled nursing facility, the benefit period will end when you go 60 consecutive days without care in a hospital or skilled nursing facility. A deductible applies for each benefit period.

Your benefit period with Medicare does not end until 60 days after discharge from the hospital or the skilled nursing facility. Therefore, if you are readmitted within those 60 days, you are considered to be in the same benefit period. If you are readmitted within 60 days, you are not charged another deductible. There is no limit on the number of benefit periods Medicare will cover in your lifetime.

Example: 

Uncle George goes into the hospital June 1 and is discharged July 31. On November 1, he is readmitted to the hospital. He pays his deductible again because he is starting a new benefit period. If George had been re-admitted to the hospital within 60 days of his July 31 discharge, there would have been no additional deductible.

Coverage for Inpatient Hospital Care

For inpatient hospital stays, Original Medicare will pay:

  • 100% of costs for Days 0-60 of inpatient care, after you pay the deductible. (In 2017, the Part A deductible is $1316.)

For Days 61-90, beneficiaries are responsible for coinsurance costs. (In 2017, beneficiaries must pay $329 per day.) Beneficiaries are entitled to use lifetime reserve days (60 additional days) after Day 91. If those reserve days are used, beneficiaries must pay $658 per day in 2017. If you choose not to use your lifetime reserve, all Medicare coverage stops after 90 days of inpatient care or after 60 days without any skilled care for this benefit period.

Example:

Grandpa is admitted to the hospital September 1, 2017. After he pays the deductible of $1,316, Medicare will pay for the cost of his stay for 60 days. If he stays in the hospital beyond 60 days, he will be responsible for paying $329 per day, with Medicare paying the balance.

If Grandpa has supplemental insurance, he can submit a claim for the $1,316 deductible and the $329 per day he paid. If he stays longer than 90 days, he may choose to use some of his lifetime reserve days to continue his Medicare coverage. If he does, he is responsible for paying $658/day for any days after 90 days, which, again, he can submit to his supplemental insurance company.

Part A coverage pays for all Medicare-approved inpatient hospital costs except for your physician bills, which are covered under Part B. Medicare approves costs considered reasonable and medically necessary.

Specific Services Covered Under Part A

Specific services covered under Part A include:

  • A semiprivate room
  • Meals
  • Nursing services, including nursing in special care units such as intensive care
  • Medications administered while in the hospital
  • Clinical laboratory tests
  • X-ray and radiotherapy
  • Medical supplies, such as dressings and intravenous lines
  • The use of equipment such as wheelchairs
  • Operating room and recovery room charges
  • Rehabilitation services, such as physical therapy and speech pathology, provided in the hospital.

Medicare will not pay for items considered luxuries, such as a television in your room or for a private room, unless your condition renders it medically necessary.

Coverage for Skilled Nursing Facility Care

What is a skilled nursing facility? A skilled nursing facility provides medically necessary nursing and/or rehabilitation services.

To receive Medicare coverage for care in a skilled nursing facility:

  • A physician must certify that you require daily skilled care that can only be provided as an inpatient in a skilled nursing facility
  • You must have been an inpatient in a hospital for at least three consecutive days for the same illness or condition before being admitted to the skilled nursing facility
  • Your admission to the skilled nursing facility must be within 30 days of discharge from the hospital
  • The facility must be Medicare-approved to provide skilled nursing care

Coverage is limited to a maximum of 100 days per benefit period, with coinsurance requirements of $164.50 per day in 2017 for Days 21 through 100.

Coverage includes:

  • A semiprivate room
  • Meals
  • Rehabilitation services
  • Prescription drugs administered while in the facility

Coverage for Home Health Care

Home health care is care provided to you at home, typically by a visiting nurse or home health care aide. Medicare Part A covers medically necessary home health care offered by a provider certified by Medicare to provide home health care. Medicare pays the lower of:

  • The actual cost for Medicare approved services,
  • An aggregate per visit limit, or
  • An aggregate per beneficiary limit

To receive home health services under Medicare, the following rules apply:

  • You must be confined to your home
  • Your physician must certify the care as medically necessary and approve the treatment plan

You should also be aware that:

  • Medicare does not cover care that is primarily custodial, such as assistance in performing daily tasks
  • Medicare will cover services such as nursing service, physical therapy, speech therapy, occupational therapy, and 20 percent of the cost of durable medical equipment, such as a wheelchair
  • Currently there are no benefit periods, deductibles, co-payment, or coinsurance requirements for home health care .

Example: 

Following her back operation, Mom was confined to her home. Medicare covered the cost of visiting nurses who came to her home to change her surgical dressing and provide other necessary skilled nursing care. Medicare also covered the cost of care Mom received from a physical therapist who came to her home three times a week.

Coverage for Psychiatric Hospitalization

For inpatient psychiatric care, Medicare Part A will pay for the same kinds of services as if you were hospitalized in a general hospital:

  • Semiprivate room
  • Meals
  • Nursing care
  • Rehabilitation services, such as physical or occupational therapy
  • Prescription drugs administered in the hospital
  • Medical supplies
  • Lab tests, X-rays, and radiotherapy

An important distinction from care in a general hospital is that you must use a facility that accepts Medicare assignments on all claims. Deductibles and coinsurance costs are the same as for a regular inpatient hospital stay. In the course of your life, Medicare will only pay for 190 days of inpatient psychiatric care (lifetime limit).

Coverage for Hospice Care

Hospice care for the terminally ill is covered by Medicare Part A. It is comprehensive coverage, at home or in a facility where you live, for symptom management and pain control for the terminally ill. To receive coverage:

  • The health-care provider must be certified by Medicare to provide hospice care
  • The patient's doctor and the hospice care director must certify that the patient is terminally ill (i.e., has a life expectancy of six months or less)
  • The patient must elect hospice coverage for the terminal illness instead of standard Medicare benefits, although Medicare will continue to cover care provided that it is not related to the terminal illness

Services include nursing care, medical appliances and supplies, prescriptions, home health aide and homemaker services, medical social services, and counseling.

Example: 

Sue is 95 and has terminal cancer. She decided she would rather have hospice care under her Medicare coverage so that she can stay at home and receive assistance to live her final days in as much comfort as possible. She receives pain medication, counseling, and assistance with meal preparation and other household tasks. Sue falls and breaks her hip. She will receive her regular Medicare coverage for treatment of her hip.

There are two categories of costs for which a Medicare hospice patient may be responsible:

  • A co-payment of up to $5 for each outpatient prescription for pain relief or symptom management.
  • Respite care. The hospice may arrange for the hospice patient to be moved to an inpatient facility for up to five days at a time to provide respite to the hospice care personnel. The Medicare beneficiary may be charged a nominal daily fee for the inpatient care (5 percent of the Medicare-approved amount for in-patient respite care). Note, too, that Medicare does not cover room and board when you get hospice care in your home or a facility where you live.

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Last Revised 11/15/2017