Medicare Part A

Medicare Part A

What is the cost for Medicare Part A?

Most beneficiaries are automatically enrolled in Part A if they have worked for 10 years.

Most people don’t have to pay a monthly payment (premium) for Medicare Part A because they or their spouse paid Medicare or FICA taxes while in the workforce. (FICA stands for Federal Insurance Contributions Act. It’s the tax withheld from your paycheck, or that you pay based on your self-employment income, that funds the Social Security and Medicare programs.)

If you or your spouse did not pay Medicare taxes while you were working, or if you or your spouse did not work long enough (10 years) in Medicare-covered employment to qualify for premium-free Medicare Part A, you may still be able to get Medicare Part A. However, you will have to pay a monthly premium. The amount of the premium depends on how long you or your spouse worked in Medicare-covered employment.

What does Medicare Part A cover?

Medicare Part A helps pay for:

  • Inpatient Hospital Stays
  • Skilled Nursing Facility (SNF)
  • Home Health Care
  • Hospice

Inpatient Hospital Stays

Covered services for hospital inpatients include semi-private room, meals, general nursing and other hospital services and supplies. This includes:

  • inpatient care you get in acute care hospitals
  • in critical access hospitals (small facilities that give limited services to people in rural areas)
  • as part of a clinical research study
  • mental health care (Inpatient mental health care coverage in an independent psychiatric hospital is limited to 190 days in a lifetime. Lifetime reserve days can be used for psychiatric care, bringing the total available days to 250.)

Coverage does not include private duty nursing, the first three pints of blood you may receive or a private room unless medically necessary.

Cost for Inpatient Hospital Stays

The beneficiary is responsible for deductible for each benefit period.

What is a benefit period?

A benefit period refers to the way Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you are admitted to a hospital as an inpatient. The benefit period ends when you have not received Medicare-reimbursed hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

Skilled Nursing Facility (SNF)

Medicare Part A will pay for skilled nursing facility care for people with Medicare who meet all of the following conditions:

  • Your condition requires daily skilled nursing or skilled rehabilitation services which can only be provided in a skilled nursing facility.
  • You were an inpatient in a hospital 3 consecutive days or longer, not counting the day you leave the hospital, before you were admitted to a participating SNF.
  • You were admitted to the SNF within 30 days after leaving the hospital.
  • Your care in the SNF is for a condition that was treated in the hospital.
  • The facility must participate in Medicare.

What is covered?

If you qualify, Medicare will cover the following SNF services; semi-private room, meals, skilled nursing care, physical, occupational and speech therapy, medical social services, medications and medical supplies/equipment used in the facility. Skilled care does not cover custodial care (also known as assistance with activities of daily living) which includes assistance with bathing, dressing, walking, and eating, if this is the only purpose of the skilled nursing stay.

What is the cost?

Skilled nursing facility care is covered in full for the first 20 days when you meet the requirements for a Medicare-covered stay. Under original Medicare, for days 21-100, SNF care has a per day cost. After 100 days, Medicare Part A no longer covers SNF care. You can qualify for skilled nursing care again every time you have a new benefit period.Keep in mind that skilled nursing care is different from nursing home care.

Home Health Care

Medicare Part A pays for your home health services for as long as you are eligible and your doctor says you need these services. (Part B also may pay for home health care under certain conditions.) To be eligible, you must meet four conditions:

  • Your doctor must decide you need skilled care in your home and must make a plan for your care at home.
  • You must need at least on of the following services: Intermittent (not full-time) skilled nursing care, physical therapy, speech language services, or continue to need occupational therapy.
  • You must be homebound, which means that you are normally unable to leave home or that leaving home is a major effort.
  • The home health agency caring for you must be approved by Medicare.

What is the cost?

If you qualify, home health care is fully covered by Medicare for each 60-day period that you need care. Your doctor and home health agency staff review your plan of care at least once every 60 days. You will continue to get home health care for as long as you are eligible.

Hospice

Part A also covers hospice care, which is a special way of caring for people who are terminally ill and their families. Hospice care is meant to help you make the most of the last months of life by giving you comfort and relief from pain. It involves a team that addresses your medical, physical, asocial, emotional, and spiritual needs. The goal of hospice is to care for you and your family, not to cure your illness. You can get hospice care as long as your doctor certifies that you are terminally ill and probably have less than 6 months to live if the disease runs its normal course.

Care is given in “periods of care”—two 90 day periods followed by unlimited 60 day periods. At the start of each period of care, your doctor must certify that you are terminally ill for you to continue getting hospice care. Medicare must approve the hospice care provider. You must sign a statement choosing hospice care instead of routine Medicare covered benefits to treat your terminal illness. However, medical services not related to the hospice condition would still be covered by Medicare.

What is Covered?

The hospice benefit covers many services, in addition to the regular Medicare-covered services such as doctor and nursing care, physical and occupational therapy, and speech therapy, the hospice benefit also covers:Medical equipment, medical supplies, drugs for symptom control and pain relief, short term care in the hospital when needed for pain and symptom management, home health aide and homemaker services, social worker services, dietary counseling, grief counseling for patient and family, inpatient respite care.

CLAIM TIP: When on hospice, before receiving any services always contact your hospice representative!

What is the cost?

For hospice care in Original Medicare, you pay a co-payment of no more than $5 for each prescription drugs for pain relief and 5% of the Medicare approved payment amount for inpatient respite care. These costs are covered under most Medicare Supplement (Medigap) policies.

Claims

Participating hospitals, skilled nursing facilities, home health agencies, and hospice agencies are required to fill all claims with Medicare.When a beneficiary uses a Part A service, they should receive either a Medicare Summary Notice. This statement provides detailed information regarding the service, such as dates of service, amount billed to Medicare and amount the beneficiary owes the provider. This statement will also provide information on how to appeal any denied services.When Medicare denies payment for a service, you have a right to appeal the decision. Each level of appeal has its own guidelines and time restraints. You are always given information on how to appeal or further appeal a decision.

Part B (medical) 

Medicare Advantage

Part D (prescription)