Medicare Part A covers various costs normally incurred during hospital stays, but it also provides eligible beneficiaries with other types of coverage, including skilled nursing facility stays, hospice care, and home health care services.
Here’s a look at the services Medicare Part A covers according to the type of facility and care, as well as the costs and limitations:
Medicare Part A covers the cost of your care as an inpatient in hospitals and certain other medical facilities that accept Medicare, but only if you’re admitted under a physician’s order stating inpatient care is necessary to treat an injury or illness. Other covered facilities include long-term care, acute care, and critical access hospitals, as well as rehabilitation and mental health care facilities.
During a hospital stay, Medicare Part A covers the cost of:
Medicare Part A doesn’t pay for a private room unless it’s deemed medically necessary. It also doesn’t cover extra amenities, such as private-duty nursing care, an in-room telephone or television if they’re billed separately, or personal care items, such as slippers and razors.
Admission to a Medicare-certified skilled nursing facility (SNF) is covered by Medicare Part A if certain conditions are met. To qualify, your physician must determine that you require daily skilled care after a minimum three-day inpatient hospital stay, not including the day you’re discharged. You may also qualify for coverage if you have a condition that began while you were in an SNF due to a hospital-related medical condition.
Medicare Part A covers a number of costs during an SNF stay, including:
Medicare Part A also covers dietary counseling, medical social services, and ambulance transportation for necessary services not available at your skilled nursing facility.
Medicare Part A covers the cost of certain home health care services if they’re medically necessary and ordered by your physician as part of a treatment plan. Your physician must also certify that you require covered care services and that you’re homebound per Medicare’s criteria.
The home care services you receive must be provided by a Medicare-certified agency and may include:
Medicare Part A doesn’t cover the cost of meals, 24-hour in-home care, a homemaker, or personal care services if they’re not related to your physician-ordered treatment plan or are the only services you need.
Medicare covers hospice care for Part A beneficiaries who receive a physician’s certification of a terminal illness with a life expectancy of up to six months. To be approved, you must sign a statement agreeing to receive palliative care for comfort rather than care or treatment to cure your illness or related conditions. Covered services may be provided where you live, whether at home, in a nursing home, or in a hospice inpatient facility.
Medicare Part A covers many hospice services depending on your illness and related conditions. These services can include:
Medicare Part A also covers social work services, dietary counseling, physical and occupational therapy, speech pathology services, and grief counseling for family members. However, it doesn’t cover room and board costs, regardless of whether you receive hospice services at home, in a nursing home, or in an inpatient facility.
Most individuals who meet the eligibility requirements for Medicare Part A receive coverage without paying any recurring monthly costs. To qualify for premium-free Part A, you must have accrued 40 quarters of coverage (QC) by paying Social Security taxes during your working years or through the earnings record of your spouse, parent, or child. Individuals who don’t have the required number of QCs to qualify for free coverage can buy into the program and pay a monthly premium.
Deductibles and coinsurance costs for certain types of Medicare Part A coverage are also in place:
The costs of premiums, deductibles, and coinsurance under Medicare Part A are updated annually. Once you reach the maximum number of coverage days for either type of care, you’re responsible for all costs.
You can qualify for home health or hospice care without first being a hospital inpatient, and there are no deductibles or coinsurance costs. These two types of care aren’t limited to a maximum number of coverage days; however, your doctor must re-evaluate and certify your need for covered services every 60 days.
Although the Medicare program is administered by the Centers for Medicare & Medicaid Services (CMS), eligibility is handled by the Social Security Administration (SSA) and limited to American citizens and lawful permanent residents with at least five years of full-time U.S. residency. You can qualify for Medicare if you’re over age 65, deemed disabled, or apply for SSDI after being diagnosed with ESRD or ALS.
Key eligibility points include:
Enrolling in Medicare Part A when you first become eligible not only ensures you have adequate health care coverage, but it may also help you avoid having to pay a late sign-up penalty in certain situations. How and when you can enroll depends on your age and whether you’re already receiving Social Security, Railroad Retirement, or disability benefits.
Key enrollment points include:
If you have to pay a monthly premium for Medicare Part A coverage, you can only sign up during the following three defined enrollment periods. Each period has specific rules, time frames for applying, and start dates for coverage.
When you become eligible for Medicare, you’re entitled to a seven-month-long initial enrollment period (IEP) that consists of the three months before your 65th birthday, your birthday month, and the three months following your birthday month. If you sign up during the first three months of your IEP, your coverage is retroactive to the month you became eligible for Medicare. Signing up during any other month delays your coverage start date. If you qualify for premium-free coverage but weren’t enrolled automatically, you can sign up at any point during or after your IEP.
Medicare offers an annual general enrollment period (GEP) from January 1 through March 31. If you apply for Medicare Part A during a GEP, your coverage begins on July 1 of that same year.
If you delayed signing up for original Medicare because you were working for a company with more than 20 employees when you turned 65 or had other health insurance, you may be entitled to an eight-month special enrollment period (SEP). You can qualify for an SEP if you kept your group health insurance through your employer or union or had coverage through your spouse’s employer. Your SEP begins the month after your employment or group coverage ends, whichever occurs first.
A benefit period is how Medicare measures your use of Part A hospital inpatient and SNF services to determine which costs are your responsibility. A period begins when you’re admitted as a hospital inpatient and ends when you haven’t received Medicare-covered services in a hospital or SNF for 60 consecutive days. The number of benefit periods you qualify for isn’t limited, but you must pay a deductible for each period and coinsurance after a certain number of days of coverage.
To be certified as homebound and receive home health care services through Medicare, you must meet certain criteria. You must leave home rarely and require assistance or rely on medical equipment to ambulate, such as a walker, wheelchair, or crutches. Furthermore, your physician must believe that leaving your home will worsen your illness or health condition. Leaving home occasionally to receive medical treatment or attend adult day care or religious services is permitted. You can also leave for short periods to attend a funeral, graduation, family reunion, or other such event and still qualify as homebound.
If you apply for premium Medicare Part A coverage but don’t enroll when you first become eligible, you may have to pay 10% more per month. This late enrollment penalty lasts for twice the length of time you were eligible but didn’t enroll. For instance, if you delayed your enrollment for a year, you will pay a 10% higher premium each month during your first two years of coverage.