Medicare Part A
Medicare Part A provides benefits if a patient meets the following requirements:
- He is under the care of a licensed physician
- He requires care that can only be provided in a hospital
- The facility has been designated and approved by Medicare as a participating hospital
- He is admitted under a code deemed medically necessary
What does Medicare Part A cover?
Medicare Part A is hospital coverage and covers the following inpatient hospital services:
- Hospital inpatient care
- Semi-private room (If a private room is deemed medically necessary, Medicare will cover the charge. If a patient insists on a private room when it is not required, Medicare will pay the semi-private rate and the patient will be responsible for the remainder of the cost.)
- General nursing provided by licensed registered nurses
- Care provided by interns or residents of an approved teaching hospital
- Hospital services and supplies
- Hospital operating rooms, recovery room, and anesthesia
- Drugs administered as part of inpatient treatment
- Rehabilitation services
- Skilled nursing facility care (not long-term care)
- Home health care
- Hospice care
- Blood (after the first three pints)
What is not covered by Medicare Part A
- Private duty nursing
- Private room (Unless the doctor requires it as medically necessary)
- In-room television and phone (If billed separately from the room charge)
- Personal care items (slippers, socks, razors)
- The first three pints of blood (A donation by the patient or another person’s donation on behalf of the patient would waive the blood deductible.)
- Physician’s and surgeon’s services (These would be covered under Medicare Part B.)
Medicare Part A will also cover inpatient services in a psychiatric hospital but these benefits are limited to a lifetime maximum of 190 days. If a patient is already hospitalized in a psychiatric hospital when he turns 65, the lifetime maximum is reduced to 150 days and the days already spent will be counted against the 150-day maximum.
Care in a Skilled Nursing Facility (SNF)
Medicare Part A also provides for care in a skilled nursing facility (SNF) as long as the patient has spent three consecutive days as an admitted patient in a hospital for the same condition within the prior 30 days. The day of release does not count. This three-day requirement is sometimes referred to as the “Three Midnight Rule.” The maximum allowable period of coverage is 100 days per benefit period. While the first 20 days are covered under the original $1316.00 benefit period deductible, the remaining days carry a daily $164.50 co-payment. The care received in an SNF is not custodial in nature, meaning care related to bathing, dressing, feeding, or transferring.
The care provided by an SNF must be:
- Under the supervision of licensed physicians and registered nurses
- Provided on a 24-hour basis
- Provided for patients in need of skilled care or rehabilitation on a daily basis. (Rest days where no service is received count in this determination.
Home Health Care
Sometimes, after a patient is discharged from a hospital, he may need ongoing care which can be provided in his home rather than in an SNF. Medicare Part A covers these expenses provided that the following conditions are met:
- The care must be part of formal health care plan certified by the patient’s doctor
- The care must be part-time care
- The person must be confined at home. (Travel to the doctor’s office or for religious services are allowed.)
- The home health care provider must be a participating agency approved and certified by Medicare
A patient covered by home health care may receive:
- Physical, occupational, and speech therapy
- Part-time services of a home health aide to administer medications or change dressings
- Medical social services
- The use of certain medical equipment such as wheelchairs or hospital beds (A 20% coinsurance may apply for these items as this benefit falls under Medicare Part B.)
If a patient’s doctor certifies him as terminally ill (with an expected life expectancy of not more than six months), Medicare Part A will pay for hospice care. The cost is covered in full except for a 5% co-payment for prescription medication (with a maximum co-payment of $5.00) and a 5% copayment for inpatient respite care so that caregivers may receive a break from continual care. The total copayment is capped at the current Part A deductible of $1316.00.
While in hospice, a patient will receive services to control pain; treatment of the illness is not offered and life support systems are not used. The purpose of hospice care is to allow a patient to die with dignity.
While in hospice, a patient and his family may receive
- Care provided by nurses and physicians
- Medical social services including grief counseling
- Drugs for the control of pain
- Home health aide services
- Short-term inpatient care for the control of pain or to provide respite care
If the patient lives beyond the six-month window originally certified by his physician, he may be recertified as terminally ill for another six-month period.
Here are some examples of copay costs under the hospice provisions of Medicare Part A:
Carl, admitted to hospice, requires pain medication that costs $30.00 per prescription. His copayment is 5% x $30.00 which equals $1.50 per prescription.
If Carl is admitted to a hospice for respite care and the daily hospice charge is $300, his copayment would be 5% x $300.00, or $30.00 per day.
If a person is admitted to a nursing home for care that is custodial in nature, Medicare typically pays nothing. Medicaid will pay nursing home expenses but only after the patient has paid down his own resources to the point where he is at the poverty level.
Who is eligible for Medicare Part A
Citizens or permanent residents of the United States are eligible for Medicare Part A at 65 at no cost if any of these conditions apply:
- They receive or are eligible to receive Social Security benefits because either they or their spouse paid Medicare taxes for at least 10 years or 40 quarters.
- They receive or are eligible to receive Railroad Retirement benefits
- Their spouse, whether living, deceased, or divorced, receives or is eligible to receive Social Security or Railroad Retirement benefits
- Either they or their spouse worked long enough at a government job through which Medicare taxes were paid
- They are the dependent parent of a fully insured deceased child.
Those who don’t meet these requirements may still enroll in Medicare Part A by paying a monthly premium of up to $441.00.
Citizens or permanent residents younger than 65 are eligible for Medicare Part A coverage at no cost if any of these conditions apply:
- They have been entitled to Social Security disability benefits for 24 months
- They have received a disability pension from the Railroad Retirement Board and meet certain conditions
- They receive Social Security disability benefits because they have Lou Gehrig’s disease (ALS)
- They are the child or widow(er) age 50 or older, including a divorced widow(er) of someone who has worked long enough in a government job through which Medicare taxes were paid and meet the requirements of the Social Security disability program
- They have permanent kidney failure and receive maintenance dialysis or a kidney transplant and meet certain conditions.
If you haven’t met any of the listed conditions and aren’t eligible for premium-free Medicare Part A, you may purchase the coverage for $413 each month in 2017.
2017 Deductibles for Medicare Part A
The 2017 Part A deductible for each benefit period* is $1316 and the coinsurance changes depending on the length of one’s hospitalization:
2017 Medicare Part A Hospital Co-insurance
- Days 1 – 60: $0.00 coinsurance After the patient satisfies the $1316 deductible, Medicare pays for all covered inpatient expenses.
- Days 61 – 90: $329 coinsurance per day
- Days 91 – 150 $658 coinsurance per day for these lifetime reserve days. A patient has only 60 lifetime reserve days and once they’re used, he is responsible for the total cost.
*The Medicare Part A benefit period begins the first day a patient stays overnight as an admitted patient in a hospital and continues until that patient has been out of the hospital for 60 days. If a patient goes into the hospital more than 60 days after having been released, a new benefit period begins and a new $1316 deductible is payable. Thus, there is no limit to the number of benefit periods a patient may have to pay for.
Here is an example of how the Medicare Part A out-of-pocket expenses would be figured for Dan, a Medicare enrollee, who was hospitalized for 75 days due to open-heart surgery and a stroke.
|Days 1 – 60||$0.00|
|Days 61 – 75 (15 days at $329/day)||$4935.00|
|Total out-of-pocket for Part A||$6251.00|
2017 Deductibles for Skilled Nursing Facility Care
- Days 1 – 20: $0.00 coinsurance
- Days 21 – 100: $164.50 coinsurance per day
- Over 101 Days: The patient is responsible for all costs
A review of the deductibles, copayments and coinsurance required by Medicare Part A reveals that there are many substantial gaps in the coverage that Medicare provides. Most of these gaps can by filled very effectively by a Medicare supplement insurance policy. To speak with a licensed agent about how you can be protected from these unpredictable and possibly ruinous costs, please contact us at (888) 860-1002 for a free consultation. As an independent insurance broker, we are licensed and appointed with all the major carriers and can recommend a policy that will cover these expenses at a reasonable cost. Our services are always free and we track your premiums annually to monitor for increases so that we can always keep you with the lowest cost provider. It’s our job to keep an eye on that so that you don’t have to.