What You Need to Know About Medicare: Medicare Part A

Medicare Part A is the “hospital insurance” portion of Medicare. For most people who have paid Medicare taxes throughout their working life, there is no premium for Medicare Part A coverage. If you do not qualify for premium-free Medicare Part A, it can be purchased for $471 per month (as of 2021). If you do have to pay and do not sign up when you are first eligible, you will have to pay a 10% premium above your normal monthly payment for twice the number of years you have been eligible for Medicare.

Benefit Coverage

Hospital Inpatient Stays: Medicare Part A covers inpatient hospital overnight stays, including a semi-private room, food, general nursing, diagnostic tests, blood (after you have paid for the first 3 units per calendar year), supplies considered medically necessary to treat a disease or condition, and doctors’ fees. For hospital stays, Medicare pays covered costs as follows:1

Each person has 60 days categorized as Lifetime Reserve Days to provide some coverage if hospital stays should exceed 90 days. Once the Lifetime Reserve Days have been used, Medicare will limit hospital stay coverage to 90 days.

Skilled Nursing Facility Stays: Even though Medicare Part A is a hospital insurance, there are a few very notable things excluded such as custodial, non-skilled care, long term care, and activities of daily living. It can, however, help pay for stays up to 100 days in a nursing facility if certain criteria are met:

You must have been formally admitted to the hospital within the last 30 days for at least 3 days and nights (not counting the discharge date).
The reason for the nursing facility stay must correspond to the reason for hospitalization, or it must be a condition diagnosed at the hospital.
You must require either five-day or six-day per week rehabilitation or seven-day per week skilled care.
The care provided in the nursing facility must require skilled labor and the facility must be Medicare-certified.

Medicare will pay the first 20 days of a skilled nursing facility stay in full, but the remaining 80 days require a co-payment of $185 per day (as of 2021). If you go 30 days without receiving skilled nursing, you would need a new 3-day hospital stay to qualify for additional skilled nursing care. Medicare Part A’s 100-day clock resets after you go 60 days without receiving facility-based, skilled nursing services.2

Home Health Care: Medicare Part A provides for some home health care under limited circumstances. A visit can be from a nurse, physical therapist, occupational therapist, speech therapist, or a home health aide. Medicare will also pay 80% of the Medicare-approved amount for durable medical equipment.3 Your doctor and home health team must review your plan of care as often as necessary, but at least once every 60 days.

In order to qualify for home health care coverage, you must meet all the following conditions:

You must be under the care of a doctor and you must be getting services under a plan of care established and reviewed regularly by a doctor.
You must need, and a doctor must certify that you need, one or more of the following:
Intermittent skilled nursing care
Physical therapy
Speech-language pathology services
Continued occupational therapy
The home health agency caring for you must be approved by Medicare.
A doctor must certify that you’re homebound. This means any of the following:
Leaving your home isn’t recommended because of your condition and requires a considerable and taxing effort.
Your condition keeps you from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person).

Medicare pays your Medicare-certified home health agency one payment for the covered services you get during a 60-day period. This 60-day period is called an “episode of care.”4 The payment is based on your condition and care needs.

Long-term Care Hospitals: Medicare will cover some benefits you receive if you have to go into a long-term care hospital. Long-term care hospitals specialize in treating patients who have serious conditions but potentially can improve and return to their homes. Under this arrangement eligible participants would be responsible for paying a deductible for the benefit period.

Under Medicare, you’re only responsible for one deductible for any benefit period. This applies whether you’re in an acute-care or long-term care hospital.You don’t have to pay a second deductible for your care in a long-term care hospital if:5

You’re transferred to a long-term care hospital directly from an acute care hospital.
You’re admitted to a long-term care hospital within 60 days of being discharged from an inpatient hospital stay.

If you’re admitted directly to a long-term care hospital more than 60 days after any previous hospital stay, a new benefit period begins and you pay the same deductibles and coinsurance as you would if you were being admitted to an acute-care hospital.

Hospice Care: Medicare will cover some hospice benefits for those who are terminally ill. This coverage is normally provided in the patient’s home and does not include the cost of room and board where the patient lives, but if the normal caregiver needs a break, a hospice facility will be 95% paid for by Medicare.6 Medicare hospice care also provides outpatient prescription drug benefits for pain and symptom management with a co-payment of up to $5. If the drug is not covered under the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it’s covered under Part D.

Sources

“Medicare 2020 Costs at a Glance.” www.medicare.gov, www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html.
“Skilled Nursing Facility (SNF) Care.” www.medicare.gov, www.medicare.gov/coverage/skilled-nursing-facility-care.html
“Home Health Services.” www.medicare.gov, www.medicare.gov/coverage/home-health-services.html.
“Medicare and Home Health Care.” cms.gov, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Downloads/HHQIHHBenefits.pdf.
“Long-Term Care Hospitals.” www.medicare.gov, www.medicare.gov/coverage/long-term-care-hospitals.html.
“Hospice & Respite Care.” www.medicare.gov, www.medicare.gov/coverage/hospice-and-respite-care.html.