Medicare Part A explained – Understanding Medicare hospital coverage
Medicare is a medical insurance offered by the U.S. federal government to U.S. citizens that have reached the age of 65 or older. Also, Medicare is available to some individuals under the age of 65. These individuals have certain diseases or receive disability benefits from the Social Security Administration or the Railroad Retirement Board.
If you are already receiving Social Security benefits or Railroad Retirement board benefits when you turn 65, you will be automatically enrolled in Medicare Part A and B. You will receive a Medicare card in the mail three months before you turn 65. If you are disabled and under 65, you will qualify for Medicare 24 months after you start receiving Social Security benefits. If you have amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease), you will qualify for Medicare Part A the month your disability benefits begin. Those that have End Stage Renal Disease also qualify, regardless of their age; these beneficiaries are required to apply for benefits when first diagnosed.
Medicare is a federal medical insurance program that is composed of four parts: Part A, Part B, Part C and Part D. Most individuals don’t have to pay a monthly premium for Part A, because they earned 40 credits while employed. This is achieved by paying payroll taxes for at least 10 years while working. Those that qualify for Part A usually also qualify for Part B. You can decide whether you want to accept the Part B coverage, because there is a monthly premium for Medicare Part B. Under the Affordable Care Act, having Part A coverage alone is sufficient to meet the minimum standard of coverage required.
Medicare Part A is also known as hospital insurance, because it is the part of Medicare that covers inpatient hospital stays. Medicare coverage will pay for semiprivate rooms, general nursing care, meals, medications while in the hospital and all other services and care during an inpatient hospital visit.
Medicare coverage applies to the following facilities: acute care hospitals, inpatient rehabilitation facilities, critical access hospitals, long-term care hospitals, mental health care and inpatient care that falls under a qualifying clinical research study.
Things that are not covered under Medicare Part A include private duty nursing, private rooms that are not medically necessary, telephones and televisions that warrant extra expenses and personal grooming items. There are several factors that determine whether Medicare Part A deems your inpatient hospital visit to be qualified and therefore, covered by your plan. First, a medical doctor makes an official medical order that states that your illness or injury required inpatient medical care. The care you need can only be received in a hospital. The hospital must accept Medicare insurance, and a Utilization Review Committee specific to the hospital determines that your stay is approved.
Medicare Part A covers skilled nursing facility (SNF) care. While in the SNF, the following are covered:
- Semiprivate rooms
- Skilled nursing care
- Physical and occupational therapy
- Medical social services provided through a social worker or other social service provider
- Speech and language pathology services
- Medical supplies and equipment used in the facility
- Dietary counseling
- Ambulatory services, in life or death situations.
In order for Medicare Part A to cover a skilled nursing facility, the following things must happen:
- You must have Part A, and you must have days left in your benefit period.
- There must have been an immediate prior inpatient hospital stay that was approved by a physician. This means that the person went to the SNF after spending at least three days and two nights in inpatient hospital care.
- Your physician must specify that you must have SNF care. Your SNF eligibility can be impacted if there is a break in your SNF care. If you leave the SNF facility for 30 days or more, you may need to have a three-day qualifying inpatient stay to qualify for Medicare Part A to cover SNF again. If there is a break in SNF care for 60 consecutive days, your current benefit period ends and a new benefit period begins.
Medicare Part A also covers services in a long-term care hospital (LTCH). These facilities specialize in treating patients with more than one serious medical condition that requires additional healthcare and time before returning home. If you must go to a LTCH, you will not pay a higher deductible. The deductibles for acute care and long-term care facilities are the same. In addition, you will only have to pay one deductible per benefit period.
If the following conditions are met, you will not have to pay a second deductible for a stay in a LTCH. This applies whether an acute hospital transfers you directly to the LTCH or if you are admitted to the LTCH within 60 days of being discharged from an acute hospital. However, if you are admitted to a LTCH after 60 days, you pay the same deductible and coinsurance that you would have paid if admitted to an acute care hospital.
Medicare Part A is critical coverage for those who are 65 years or older or those under 65 with a disabling condition. This coverage pays for most of your inpatient hospital needs, with the exception of the deductible and coinsurance. Utilizing your Medicare Part A insurance will substantially reduce the medical bills that you are responsible for after you are qualified to receive Social Security or Railroad Board benefits.