Hospital Coverage
What is Medicare Part A?
There are different parts of Original Medicare. You will have hospital insurance (Medicare Part A) and medical insurance (Medicare Part B). Part A, the hospital insurance, will cover inpatient care, such as staying in a hospital, living in a skilled nursing facility, and some medical services that may be needed while living at home.
What is The Premium cost for Part A?
Premium-free Part A
You usually don’t pay a monthly premium for Medicare Part A (Hospital Insurance) coverage if you or your spouse paid Medicare taxes for forty quarters (ten years) during your working life. This is sometimes called “premium-free Part A.” Most people get premium-free Part A.
You can get premium-free Part A at 65 if:
- You already get retirement benefits from Social Security or the Railroad Retirement Board.
- You’re eligible to get Social Security or Railroad benefits but haven’t filed for them yet.
- You or your spouse had Medicare-covered government employment.
If you’re under 65, you can get premium-free Part A if: - You got Social Security or Railroad Retirement Board disability benefits for 24 months.
- You have End-Stage Renal Disease (ESRD) and meet certain requirements.
Part A premiums
If you don’t qualify for premium-free Part A, you can buy Part A.
People who buy Part A will pay a premium of either $259 or $471 each month in 2021 depending on how long they or their spouse worked and paid Medicare taxes. If you choose NOT to buy Part A, you can still buy Part B.
In most cases, if you choose to buy Part A, you must also:
- Have Medicare Part B (Medical Insurance)
- Pay monthly premiums for both Part A and Part B
Contact Social Security for more information about the Part A premium.
What does Medicare Part A cover?
Medicare Part A covers several medical services which include the following:
- Inpatient care – Some of these things would consist of meals, semi-private rooms, nursing services, inpatient treatment medications, supplies used from the hospital during their inpatient stay, and some other services.
- Hospice care – If a doctor has determined that a patient is terminally ill and will only live for six months or less, they could get Part A coverage for hospice.
- Care received during a stay in a skilled nursing facility – Nursing home stays will be covered with Part A if the patient had an inpatient hospital stay first for the related injury or illness (this does not include custodial or long-term care).
- Nursing home care (inpatient care in a skilled nursing facility that’s not custodial or long-term care)
- Home health care – If it is ordered by a doctor and deemed to be medically necessary.
Some services are only covered in certain facilities. There are also times when Medicare Part A will only cover a patient with certain conditions. It is always a good idea to speak with a Medicare specialist if you have questions about any Medicare plan.
Hospital Coverage
What is InPatient Care?
Medicare covered hospital service include:
• Semi-private rooms
• Meals
• General nursing
• Drugs as part of your inpatient treatment (including methadone to treat an opioid use disorder)
• Other hospital services and supplies as part of your inpatient treatment
Inpatient hospital care includes care you get in:
- Acute care hospitals
- Critical access hospitals
- Inpatient rehabilitation facilities
- Inpatient psychiatric facilities
- Long-term care hospitals
- Inpatient care as part of a qualifying clinical research study
Medicare Part A doesn’t include:
- Private-duty nursing
- Private room (unless medically necessary )
- Television and phone in your room (if there’s a separate charge for these items)
- Personal care items (like razors or slipper socks)
Medicare Part A Hospital Costs:
$1,408 deductible for each benefit period .
Days 1–60: $0 coinsurance for each benefit period.
Days 61–90: $352 coinsurance per day of each benefit period.
Days 91 and beyond: $704 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime).
Beyond lifetime reserve days : All costs.
Hospital Coverage
What is Hospice Care?
To qualify for hospice care, a hospice doctor and your doctor (if you have one) must certify that you’re terminally ill, meaning you have a life expectancy of 6 months or less. When you agree to hospice care, you are agreeing to comfort care (palliative care) instead of care to cure your illness. You also must sign a statement choosing hospice care instead of other benefits Medicare covers to treat your terminal illness and related conditions. Coverage includes:
• All items and services needed for pain relief and symptom management
• Medical, nursing, and social services
• Drugs for pain management
• Durable medical equipment for pain relief and symptom management
• Aide and homemaker services
• Other covered services you need to manage your pain and other symptoms, as well as spiritual and grief counseling for you and your family.
Medicare-certified hospice care is usually given in your home or other facility where you live, like a nursing home.
You pay nothing for hospice care in Original Medicare.
You pay a copayment of up to $5 for each prescription for outpatient drugs for pain and symptom management. In the rare case the hospice benefit does not cover your drug, your hospice provider should contact your plan to see if Part D covers it.
You may pay 5% of the Medicare-approved amount for inpatient respite care.
Hospital Coverage
What is Skilled Nursing Facility Care?
Medicare Part A (Hospital Insurance) covers skilled nursing care in certain conditions for a limited time (on a short-term basis) if all these conditions are met:
• You have Part A and have days left in your benefit period to use.
• You have a qualifying hospital stay
• Your doctor has decided that you need daily skilled care. It must be given by, or under the supervision of, skilled nursing or therapy staff.
• You get these skilled services in a SNF that is certified by Medicare.
• You need these skilled services for a medical condition that is either:
• A hospital-related medical condition treated during your qualifying 3-day inpatient hospital stay, even if it was not the reason you were admitted to the hospital.
• A condition that started while you were getting care in the SNF for a hospital-related medical condition (for example, if you develop an infection that requires IV antibiotics while you are getting SNF care)
Skilled care is nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel. It is health care given when you need skilled nursing or skilled therapy to treat, manage, and observe your condition, and evaluate your care.
Medicare-covered services include, but are not limited to:
• Semi-private room (a room you share with other patients)
• Meals
• Skilled nursing care
• Physical therapy (if needed to meet your health goal)
• Occupational therapy (if needed to meet your health goal)
• Speech-language pathology services (if they are needed to meet your health goal)
• Medical social services
• Limited Medications
• Medical supplies and equipment used in the facility
• Ambulance transportation (when other transportation endangers your health) to the nearest supplier of needed services that aren’t available at the SNF
• Dietary counseling
• Swing bed services
Your Skilled Nursing Facility costs in Original Medicare
You pay:
Days 1–20: $0 for each benefit period .
Days 21–100: $185.50 coinsurance per day of each benefit period.
Days 101 and beyond: All costs.
Hospital Coverage
What is Nursing Home Care?
Medicare does not cover custodial care, if it’s the only care you need. Most nursing home care is custodial care. Custodial care helps you with activities of daily living (like bathing, dressing, using the bathroom, and eating) or personal needs that could be done safely and reasonably without professional skills or training. Medicare Part A (Hospital Insurance) may cover care in a certified skilled nursing facility (SNF). It must be medically necessary for you to have skilled nursing care (like changing sterile dressings).
Hospital Coverage
What is Home Health Care?
Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover eligible home health services like these:
- Part-time or “intermittent” skilled nursing care
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social service
- Part-time or intermittent home health aide services (personal hands-on care)
- Injectible osteoporosis drugs for women
Usually, a home health care agency coordinates the services your doctor orders for you.
Medicare does not pay for:
- 24-hour-a-day care at home
- Meals delivered to your home
- Homemaker services (like shopping, cleaning, and laundry), when this is the only care you need
- Custodial or personal care (like bathing, dressing, or using the bathroom), when this is the only care you need
Who’s eligible?
All people with Part A and/or Part B who meet all of these conditions are covered:
- You must be under the care of a doctor, and you must be getting services under a plan of care created and reviewed regularly by a doctor.
- You must need, and a doctor must certify that you need, one or more of these:
Intermittent skilled nursing care (other than drawing blood) - Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either:
1) your condition must be expected to improve in a reasonable and generally predictable period of time, or
2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or
3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition. The home health agency caring for you is approved by Medicare (Medicare certified)
- You must be homebound, and a doctor must certify that you’re homebound.
You’re not eligible for the home health benefit if you need more than part-time or “intermittent” skilled nursing care. You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.
Your costs in Original Medicare
$0 for home health care services.
20% of the Medicare-approved amount for durable medical equipment (dme) .
Before you start getting your home health care, the home health agency should tell you how much Medicare will pay. The agency should also tell you if any items or services they give you aren’t covered by Medicare, and how much you’ll have to pay for them. This should be explained by both talking with you and in writing. The home health agency should give you a notice called the Advance Beneficiary Notice” (ABN) before giving you services and supplies that Medicare doesn’t cover.