Medicare Part A

Medicare Part A covers qualifying inpatient care that is received in a hospital, including critical illness hospitals. Part A will also pay for some skilled nursing facility care, as well as for certain types of home health care and hospice services.

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Part A may also provide coverage for certain types of medical social services, durable medical equipment such as wheelchairs, oxygen systems, hospital beds, walkers, and other medical supplies that can use at home.

The primary coverage provided through Medicare Part A consists of the following:

• Hospitalization – Coverage includes cost of a semi-private room as an inpatient at a hospital, general nursing services, and certain other medical supplies and hospital-related services.  All services are paid for 100% after the enrollee has paid $1,156 out of pocket.
• Blood – Medicare Part A covers 80% of the cost of blood transfusions after the first three pints are paid for by the enrollee.
• Skilled Nursing Facility Care – Skilled nursing facility coverage provided by Medicare Part A includes the cost of a room (semi-private), as well as the patient’s meals. Medicare Part A also covers skilled nursing and rehabilitative services, and certain other necessary skilled nursing facility services and supplies.  Medicare will not cover extended nursing facility stays, and coverage ends after a 20 day stay.  Medicare will cover any additional costs for the next 80 days at a cost of $144.50 per day to you, but after 100 days Medicare will not pay for additional nursing home services.
• Home Health Care Services – Home health care services that are covered by Medicare Part A are available, but are limited to reasonable and medically necessary part-time or intermittent home health aide services, physical therapy, occupational therapy, and speech-language pathology that is ordered by a doctor and is provided by a Medicare-certified home health agency.  Medicare will pay up to 80% of all medically necessary home healthcare costs.
• Hospice Care – Medicare Part A will cover certain drugs that are used for symptom control and pain relief in a hospice care setting. In addition, it may also cover medical and support services from a Medicare-approved hospice.  Medicare will cover up to 95% of the cost of hospice care.

What is Excluded from Medicare Part A Coverage?

Even though Medicare Part A covers a variety of health care expenses, there are still many gaps in coverage. For example, Part A does not include coverage for private duty nursing. Nor does it cover the cost for a private hospital room, unless it is medically necessary.

In addition, Medicare Part A does not provide coverage for inpatient mental health care in a psychiatric hospital for more than 190 days in an enrollee’s lifetime. Part A will also not cover long-term care that is considered to be “custodial” in nature, meaning that assistance with basic daily living activities such as dressing and bathing are not covered unless they are part of skilled care services.

While Medicare may not cover all of your needs completely, Medicare supplemental insurance plans are available for purchase to help cover the cost of other health care services you might need.  Fill out the zip code field to view plans available in your area and compare rates.

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How Are Medicare Part A Benefits Determined?

Medicare Part A calculates its coverage in terms of benefit periods and reserve days. A benefit period is considered to have begun on the day that a Medicare Part A enrollee enters the hospital. The person’s benefit period will end when the enrollee has been out of the hospital for at least 60 consecutive days.

Other than hospice care benefits, a Medicare Part A provides unlimited benefit periods. However, if an individual has a hospital stay of more than 90 consecutive days, any days beyond 90 will be considered reserve days.

Who Qualifies for Medicare Part A?

In order to qualify for Medicare Part A coverage, a person must be a permanent resident of the U.S. and have lived in the United States for at least five continuous years. Eligible enrollees must also be at least age 65. There are, however, some exceptions to the age 65 requirement if the person has a certain type of disability.

An individual who is suffering from end state renal disease and who requires kidney dialysis or a kidney transplant will also be considered as eligible to participate in benefits offered by Medicare Part A.

How to Enroll in Medicare Part A

In most cases, those who are already receiving benefits through Social Security or the Railroad Retirement Board will be automatically enrolled in Medicare Part A when they turn age 65. If a person is not automatically enrolled, they may apply for Medicare Part A through the office of Social Security.

All other Medicare Part A enrollees must submit an application during an “open enrollment” period. This time frame begins three months prior to the individual’s 65th birthday, includes the person’s birth month, and extends three months after the person’s birth month.

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Can Someone Enroll in Medicare Part A If They Have Other Health Insurance Coverage?

If an individual has other health insurance, they can also receive Medicare Part A. In this case, both insurance providers will be considered a “payer,” and benefits will need to be coordinated based on which payer is primary.

The primary payer (the coverage that is first in line to pay the claim) will usually pay the claim up to the limits of its coverage. Then, the secondary payer will make a claim payment on the amount that the primary insurer did not cover (if applicable).

For example, if a person filed a claim through their primary health insurance carrier and the claim is not paid within a timely manner (typically within 120 days), the health care provider may bill Medicare. Medicare could then submit a “conditional” payment, and later recover the payments that should have been made by the primary payer.

How Much Does Medicare Part A Cost?

Most enrollees in Medicare Part A do not pay a monthly premium; rather cost is determined based on need and services received. This is the case if an individual and/or the individual’s spouse paid Medicare taxes while they were working. If, however, an individual is not eligible for premium-free Medicare Part A, they may be able to purchase this coverage if they meet one of the following conditions:

• They are age 65 or over, are entitled to or are enrolling in Medicare Part B, and they meet the United States residency or citizenship requirements
• They are disabled and under age 65, and their premium-free Medicare Part A coverage ended because the individual has returned to work

If a person chooses to purchase Medicare Part A, they must also be enrolled in Medicare Part A. Therefore, these individuals will be responsible for paying the premium for both Medicare Parts A and B. Should the enrollee’s income be limited, it is possible that they may receive state assistance for these premium expenses.

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