Understanding the basics of Medicare and how it works will help lay the foundation you need to make decisions about your Medicare coverage choices. This article explains Medicare Part A (hospital insurance).
Medicare Part A is part of Original Medicare (along with Part B), the government-sponsored health insurance program for those who qualify by age, disability, or certain health conditions. Medicare is generally available to United States citizens and permanent legal residents of at least five years in a row, who are at least 65 years old or receive disability benefits. Most of those who qualify for Medicare are automatically enrolled in the program. For more information about eligibility, see Medicare Eligibility.
Most people do not have to pay a premium for Medicare Part A. If you or your spouse worked at least 10 years (40 quarters) and paid Medicare taxes while working, you’ll get premium-free Part A. If you don’t qualify for premium-free Medicare Part A, you’ll typically pay a monthly premium.
What is Medicare Part A?
Medicare Part A is hospital insurance provided by Medicare through the Centers for Medicare & Medicaid Services. Part A coverage includes (but may not be limited to) inpatient care in hospitals, nursing homes, skilled nursing facilities, and critical access hospitals. Part A does not include long-term or custodial care. If you meet specific requirements, then you may also be eligible for hospice or limited home health care.
If you’re enrolled in Original Medicare, doctors and suppliers are required by law to file Medicare claims for covered services and supplies you get. In most cases, you don’t need to file Medicare Part A claims as a beneficiary.
What does Medicare Part A Cover?
Medicare Part A is mainly hospital insurance. For coverage of doctor visits and medical services and supplies, see Medicare Part B.
Part A helps cover the services listed below when medically necessary and delivered by a Medicare-assigned health-care provider in a Medicare-approved facility. For more cost information, read about Medicare costs.
Blood transfusions
In most cases, the hospital gets blood from a blood bank at no charge, so if you receive blood as part of your inpatient stay you won’t have to pay for it or replace it. If the facility has to buy blood for you, usually you need to pay for the first three units you get in a calendar year or have it donated. Medicare Part A covers the cost of blood beyond the first three units you receive during a covered stay in a hospital, critical access hospital, or a skilled nursing facility.
Hospital stays
Medicare Part A generally covers hospital stays, including a semi-private room, meals, general nursing, and certain hospital services and supplies. Part A may cover inpatient care in:
- Critical access hospitals
- Inpatient rehabilitation facilities
- Acute care hospitals
- Qualifying clinical research studies
- Long-term care hospitals
- Psychiatric hospitals (up to a 190-day lifetime maximum)
Medicare Part A covers this care if all of the following are true:
- A doctor orders medically necessary inpatient care of at least two nights (counted as midnights).
- The facility accepts Medicare and admits you as an inpatient.
- You require care that can only be given in a hospital.
- The hospital’s Utilization Review Committee approves your stay.
Nursing home or skilled nursing facility
Medicare Part A covers limited care in a skilled nursing facility (SNF) if your situation meets a number of criteria:
- You’ve had a “qualifying inpatient hospital stay” of at least three days (72 hours). The time begins the first midnight after admission and does not include any hours on the discharge date.
- The SNF is Medicare-certified.
- Your doctor has determined you need skilled nursing care every day. This care must come from (or be directly supervised by) skilled nursing or therapy staff.
- You haven’t used all the days in your benefit period. (According to Medicare, this period begins the day you’re admitted to an SNF or a hospital as an inpatient, and ends when you haven’t had inpatient care or skilled nursing care for 60 consecutive days.)
- You require skilled nursing services either for a hospital-related medical condition, or a health condition that started when you were getting SNF care for a hospital-related medical condition.
Nursing home or skilled nursing facility stays must be related to your diagnosis during a hospital stay. For instance, suppose your hospital stay was for a stroke and your doctor determined that a nursing home or skilled nursing facility was medically necessary for your recovery. In that case, Medicare may cover a nursing home or skilled nursing facility stay for rehabilitation. A nursing home or skilled nursing facility stay includes a semi-private room, meals, and rehabilitative and skilled nursing services and care.
The coverage is limited to a maximum of 100 days in a benefit period. The first 20 days are paid in full, and the remaining 80 days will require a copayment. Medicare Part A will not cover long-term care, non-skilled, daily living, or custodial activities.
Swing beds
Certain hospitals and critical access hospitals have agreements with the Department of Health & Human Services that lets the hospital “swing” its beds into (and out of) SNF care as needed. The same cost-sharing and coverage rules apply as if these services were delivered in an SNF.
Home health services
Eligible home health services may include limited part-time care with services like intermittent skilled nursing care, physical or continued occupational therapy, home health aide service, speech-language pathology, and more. It may also include certain medically necessary in-home medical equipment (wheelchairs, hospital beds, walkers, oxygen), and other medical supplies.
Hospice care
Hospice care is for the terminally ill who are expected to have six months or less to live. Coverage includes pain-relief and symptom-control prescription drugs, medical and support services, grief counseling, and other services. Care is provided by a Medicare-approved hospice provider who will visit you at your home. Medicare also provides additional care for a hospice patient so that the usual caregiver can take a time of rest. Medicare may not cover all services that are provided to patients who receive hospice assistance.
Whatever health care insurance coverage you choose, make sure you have a clear understanding of all the options, coverage and premiums. Don’t be afraid to ask questions and seek a Medicare representative that can help you to fully understand and tell you what you will need to do to sign up.