Medicare Part A – Explaining the basics of enrollment
What is Medicare Part A? Medicare Part A is medical insurance provided by the federal government to most people who have reached the age of 65, and some who are under age 65 with certain disabling conditions. Part A helps patients pay for medically necessary care for a condition or illness that requires hospitalization.
It is provided for patients receiving care in inpatient hospitals, such as:
- Hospice care for the terminally ill
- Inpatient rehabilitation facilities
- Skilled nursing facilities as a follow-up to a hospital stay (not long-term or custodial care)
- Critical access hospitals
- Some in-home skilled nursing care for the housebound
Who is eligible for Medicare Part A?
Most beneficiaries are automatically enrolled in Part A when they apply for Medicare upon eligibility. You are eligible to be automatically enrolled in Medicare Part A free of premiums if:
- You are age 65 or older and are a U.S. citizen or legal resident who has resided in the United States for at least five years.
- You opt to receive Social Security or Railroad Retirement Board (RRB) benefits at age 65 or sooner.
- You and your spouse (or former spouse) have earned at least 40 credits (10 years’ employment) at a job in which Social Security insurance was deducted from your payment.
- You have been receiving Social Security or RRB disability payments for 24 months. In this instance, Medicare benefits will start in the 25th month of receipt of disability benefit payments.
- You have Amyotrophic Lateral Sclerosis (AML), also known as Lou Gehrig’s disease).
- You have End Stage Renal Disease (ESRD) and have received dialysis for three months or have had a kidney transplant.
You may still be able to enroll in Part A and pay a premium if you aren’t eligible for premium-free enrollment. This option is available to you if:
- You age 65 or older and are a U.S. citizen or legal resident who has resided in the United States for at least five years.
- You are under the age of 65, disabled and lost your premium-free Medicare Part A coverage because you returned to work.
- You are not eligible for premium-free Part A, but choose to enroll and pay a monthly premium for the benefits.
What does Medicare Part A cost?
Most retirees won’t pay any premiums if they paid Medicare taxes while they were employed. The premium you pay depends on the employment history of the qualifying employee. You will pay a late enrollment penalty of 10 percent of your current monthly premium if you enroll in Part A at least one year after your 65th birthday. For 2015, the premium costs are:
- $224.00 per month for enrollees having 30-39 quarters of Medicare-covered employment
- $407.00 per month for enrollees who are not otherwise eligible for premium-free hospitalization insurance and have accrued less than 30 quarters of Medicare-covered employment.
Medicare Part A hospital coverage deductible
There is a $1,260 deductible payable at the start of a hospital stay for each new benefit period for 2015. Days 1 to 60 After the deductible is met, Medicare covers, in full, the first 60 inpatient hospital days in the benefit period. The deductible is not an annual deductible. If you have multiple inpatient admissions during a benefit period, then you could pay up to four Part A deductibles in a calendar year if more than 60 days separate each hospital stay.
Coinsurance for days 61 to 90 A coinsurance payment of $315 per day is charged for days 61 through 90 per benefit period for 2015. Medicare covers the balance of the hospital bill.
Coinsurance for days 91 to 150 A coinsurance payment of $630 per day is charged for days 91 to 150 to cover these “lifetime reserve days.” Medicare covers the balance of the hospital bill.
More than 150 days The patient is responsible for any expenses accrued after the 150 days of inpatient care covered by Medicare Part A. But, if the patient leaves the hospital for 60 consecutive days, and the benefit period ends, they may then enter the hospital again with another 90 days of coverage.
Medicare Part A nursing facility coverage
Days 1 to 20 The first 20 days of inpatient care in a skilled nursing facility are covered in full. There is no deductible for skilled nursing facility coverage.
Coinsurance days 21 to 100 In 2015, a coinsurance payment of $157.50 per day is charged for each of these days. Medicare covers the balance of the bill.
More than 100 days You are responsible for all expenses accrued after the first 100 days if skilled nursing facility care continues. If the benefit period ends while the patient is away from a skilled nursing facility or hospital for 60 consecutive days, they will receive 100 additional covered skilled nursing facility days at the start of the next benefit period.
What is covered under Medicare Part A?
Medicare Part A helps pay for most care that a patient receives in a hospital or a skilled nursing facility. It also covers some home healthcare, hospice care and inpatient care in a religious nonmedical healthcare institution. Certain conditions must be met in order to get these benefits. If you are an inpatient in a hospital or skilled nursing facility, Medicare Part A will pay for:
- A semiprivate room
- Your hospital meals
- Skilled nursing services
- Drugs, medical supplies and medical equipment as an inpatient
- Care on special units, such as intensive care
- Operating room and recovery room services
- Lab tests, X-rays and radiation treatment as an inpatient
- Rehabilitation services, such as physical therapy received through home healthcare
- Some blood for transfusions in hospital or skilled nursing facility
- Care to manage symptoms and control pain for the terminally ill (hospice care)
- Skilled healthcare in your home if you’re housebound and only need part-time care
Included is inpatient care you get in: acute care hospitals, critical access hospitals, long-term care hospitals (LTCHs), inpatient rehabilitation facilities, inpatient care as part of a qualifying research study and mental health care. Inpatient mental health care in a psychiatric facility is covered for up to 190 days in a lifetime, under Medicare Part A. In some circumstances, Part A will pay the expenses for home healthcare required after you leave a hospital or skilled nursing facility. Covered items and services may include:
- Durable medical equipment, such as wheelchairs, hospital beds, oxygen and walkers
- Medically necessary part-time or intermittent, skilled nursing care and home health aide services
- Physical therapy, occupational therapy and speech language pathology ordered by your doctor and provided by a Medicare-certified home health agency
- Medical social services, including transportation to doctor appointments or home inspections to ensure your home is suitable to live in with your condition
You may be required to pay for the first three units of blood (per calendar year) for blood transfusions received in a hospital or skilled nursing facility during a covered stay. Most often, the blood is donated by a blood bank at no charge to the hospital. In that case, you will not be required to pay for or replace it.
However, if the hospital must purchase blood for you, you are required to pay the provider costs for the first three units of blood you get in a calendar year. Or, you are required to donate blood to replace the units you have used or have someone else donate on your behalf.
What is not covered by Medicare Part A?
Many doctor services are billed separately and are not part of the hospital services. Most of these doctor services are covered by Medicare Part B. You’ll have to pay the Part B deductible and 20 percent coinsurance.
Part A won’t pay the cost of “custodial care.” Custodial care is provided by a caregiver to assist a patient with the functions of daily life, such as bathing, getting dressed and eating. Even if a nurse provides this assistance, such care doesn’t require the same level of medical care provided in a hospital. As such, it is not covered. Costs considered to be of a personal nature are also not covered, such as:
- Private duty nursing
- A television or telephone in your room
- A private room, unless medically necessary
- Personal care items