• What is it?
• What does Medicare Part A Cover?
• Medicare Part A Coverage is based on Benefit Periods
• Coverage for Inpatient Care in a Hospital
• Specific Services Covered under Part A
  
• Coverage for Skilled Nursing Facility Care
• Coverage for Home Health Care
• Coverage for Psychiatric Hospitalization
• Coverage for Hospice Care

What is it?

Medicare Part A, known as hospital insurance, is the portion of Medicare that is available premium free to all eligible individuals who have paid (or their spouse has paid) Medicare taxes for at least 40 calendar quarters during their lifetime. People who are not eligible for premium-free Part A may be able to purhase Part A. Medicare Part A provides services associated with hospital, blood, hospice, skilled nursing care, and home health care. Copayments, coinsurance, and deductibles may apply for each service.

What does Medicare Part A cover?

Part A helps cover the costs associated with these types of health care:

• Inpatient hospital stays
• Stays at a skilled nursing facility (i.e., where medically necessary skilled nursing and rehabilitation care are provided), in contrast to a nursing home providing custodial care
• Home health care
• Psychiatric inpatient care
• Hospice care
• Blood (after the first 3 units)
• Religious Nonmedical Health Care Institution (Inpatient Care)

 Medicare Part A coverage is based on Benefit Periods 

 How are benefit periods determined?

A benefit period begins on the first day of your inpatient stay in a hospital or in a skilled nursing facility. A benefit period ends when you have been out of the hospital or skilled nursing facility for 60 consecutive days. If you go back in the hospital or skilled nursing facility after one benefit period has ended (you have been out of the hospital or skilled nursing facility for at least 60 consecutive days), a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There are no limits to the number of benefit periods. However, if you are readmitted within 60 days of discharge, you are considered to be in the same benefit period and will not be required to pay a new deductible.

NOTE: Medicare does not cover care that is or becomes primarily custodial, such as assistance with bathing and eating.

Example(s): Uncle George goes into the hospital June 1 and is discharged July 31 so he can keep his commitment to go skydiving on Labor Day. On November 1, he is readmitted to the hospital. Once he pays his deductible again, Medicare will pay all his costs until December 30. If, however, George is readmitted to the hospital within 60 days of his July 31 discharge, there is no additional deductible. 

Coverage for Inpatient Care in a Hospital

For inpatient hospital stays, Medicare will pay:

• 100% of costs for up to 60 days of inpatient care, after you pay the deductible of $1,132 for 2011
• After 60 days, you are responsible for coinsurance costs. In 2011, you must pay $283 per day.
• You are also entitled to a lifetime reserve of 60 additional days. If those reserve days are also used, you must pay $566 per day in 2011 for days 91 to 150.
• 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(s): Grandpa is admitted to the hospital February 2, 2011. After he pays the deductible of $1,132, Medicare will pay for the remaining cost of his stay for 60 days. If he stays in the hospital an additional 30 days, he is responsible for paying $283/day. Medicare will pay the balance. If Grandpa has supplemental insurance, he can submit a claim for the $1,132 deductible and the $283/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 $566/day for any days after 90 days, which again he can submit to his supplemental insurance company. After 150 days of a continuous inpatient stay, Medicare coverage has been exhausted for this benefit period. Most supplemental policies cover an additional 365 days in the hospital after Medicare coverage ends.

Tip: 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

Part A helps cover specific services, including:

• 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

NOTE: 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. Doctor's services you receive while in the hospital are covered under Part B.

 
Coverage for Skilled Nursing Facility Care

What is a skilled nursing facility? The short answer is--not a nursing home. Medicare does not cover nursing home care but does cover care in a skilled nursing facility, which may be housed in a nursing home or in a hospital or may be a freestanding facility. The significant attribute is the kind of care provided. 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 for 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 to receive Medicare
• 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 $141.50 per day in 2011 after Medicare pays the first 20 days at 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 medically-necessary, part-time or intermittent skilled nursing care, or physical therapy, speech-language pathology, or a ontinuing need for occupational therapy that takes place in your home. This care is provided by a doctor enrolled in Medicare, or by a nurse or home health care aide that works with your doctor. Home health services may also incude medical social services, part-time or intermittent home health aide services, and medical supplies for use at home. 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
• Your doctor must meet you in person 90 days before the start of care or within 30 days after; this may be conducted by a hospitalist even if another doctor will continue the care/care plan

You should also be aware that:

• Medicare will cover services such as nursing service, physical therapy, speech therapy, occupational therapy, and 20% of the cost of durable medical equipment, such as a wheelchair
• Currently there are no benefit periods, deductibles, copayment, or coinsurance requirements for home health care

Example(s): 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 needed nursing care. Medicare also covered the cost of therapy Mom received from a physical therapist who came to her home three times a week.

NOTE: Medicare does not cover care that is primarily custodial, such as assistance in performing daily living tasks such as bathing, dressing, eating, toileting, transferring and continence.

 
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.

 
Coverage for Hospice Care

Hospice care is care for the terminally ill. Hospice care covered by Medicare Part A is comprehensive coverage, at home, for symptom management and pain control for the terminally ill. To receive coverage:

• The healthcare 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(s): 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 only two categories of costs for which a Medicare hospice patient may be responsible:

• A copayment 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 up to 5% for the inpatient care.