Medicare Part A Explained – Understanding Medicare Hospital Coverage
Medicare is medical insurance that’s offered by the federal government to U.S. citizens that have reached the age of 65 or older. Medicare is also available to people who are under the age of 65 and have certain medical conditions, or those who 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 and 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, which is also known as Lou Gehrig’s disease, you will qualify for Medicare Part A the month your disability benefits begin. Those who have End-Stage Renal Disease (ESRD) also qualify regardless of age, but people with ESRD have to apply for benefits when first diagnosed.
Most individuals don’t have to pay a monthly premium for Part A because they earned 40 credits while working. This is achieved by paying payroll taxes for at least 10 years. If you don’t earn enough work credits to qualify for premium-free Part A, then you could pay up to $411 a month for coverage in 2016. This amount goes up each year. There are also deductibles and copayments associated with Part A.
Those who qualify for Part A usually also qualify for Part B. You can decide whether you want to enroll in 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 semi-private rooms, general nursing care, meals, medications while in the hospital, and all other services and care during an inpatient hospital visit.
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 are all covered by Medicare Part A.
Things that are not covered under Medicare Part A include private-duty nursing, a private room that is not medically necessary, a telephone and television that warrant extra expenses, and personal grooming items.
Whether Medicare Part A deems your inpatient hospital visit to be qualified and therefore covered by your plan depends on several conditions: a medical doctor has to make an official medical order that states that your illness or injury requires 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 as well. While in the SNF, the following are covered: semi-private rooms, skilled nursing care, meals, 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, medications, dietary counseling, and ambulatory services when it is a life or death situation.
In order for Medicare Part A to cover a Skilled Nursing Facility, the following must happen:
- First, you must have Part A and you must have days left in your benefit period.
There must have been an immediately prior inpatient hospital stay that was approved by a physician. This means that the person went to the Skilled Nursing Facility after spending at least three days and two nights in inpatient hospital care.
Your physician must specify that SNF care is essential.
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 3-day qualifying inpatient stay in order for Medicare Part A to cover SNF again. If there is a break in SNF care that lasts 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 long-term care hospital, you will not pay a higher deductible. The deductible for an acute care facility and a long-term care facility 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 an LTCH:
- An acute hospital transfers you directly to the LTCH
- You’re admitted to the LTCH within 60 days of being discharged from an acute hospital. However, if you are admitted to a Long-Term Care Hospital 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 a deductible and coinsurance. Utilizing Medicare Part A insurance will substantially reduce your medical bills that you are responsible for after you are qualified to receive Social Security benefits or Railroad Board benefits.