Medicare is a United States federal health insurance program that reduces the cost of healthcare services. Medicare plans cover people aged 65 or older, younger people who meet disability eligibility requirements, and individuals with specific diseases such as End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
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Eligibility & How to Enroll
You are eligible for premium-free Medicare Part A if you are age 65 or older and you or your spouse earned 40 credits or worked and paid FICA taxes for at least ten years. Those who don’t qualify for premium-free Part A will typically pay a monthly or quarterly premium.
Most of those who qualify for Medicare are automatically enrolled in Medicare Part A. Many people choose to have private insurance (such as from an employer) and Part A until they retire and begin receiving Social Security benefits.
What is Medicare Part A?
Medicare Part A (hospital insurance) is part of Original Medicare, along with Medicare Part B (medical insurance). Part A is usually premium-free.
It covers but is not limited to inpatient care in a hospital, skilled nursing facility care, short-term nursing home care, hospice care, and home health care. If you’re in a Medicare Advantage Plan or other Medicare plan, that plan may have different rules. But your plan must give you at least the same coverage as Part A Original Medicare.
What Does Medicare Part A Cover?
Medicare Part A is primarily hospital insurance. For coverage of doctor’s visits, services, and supplies, learn more about Medicare Part B. Part A covers services when medically necessary and delivered by a Medicare-assigned healthcare provider in a Medicare-approved facility.
Medicare Part A covers:
- Inpatient hospital care
- Skilled nursing facility care and short-term nursing home care
- Limited home health care
- Hospice care
Inpatient Hospital Care Coverage
When you are admitted to a hospital overnight, that is inpatient care. Part A inpatient care includes a stay in an acute care hospital, a critical access hospital, rehabilitation facilities, psychiatric facilities, a long-term care hospital, or participation in a qualifying clinical research study.
What’s Covered During Inpatient Hospital Care?
Medicare-covered hospital services include semi-private rooms, meals, general nursing, drugs, services, and supplies as part of your inpatient treatment. Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime. If you also have Part B, it generally covers 80% of the Medicare-approved amount for doctor’s services you get while you’re in a hospital.
Part A hospital insurance covers inpatient hospital care when:
- You are enrolled in Medicare Part A.
- You’re under an official doctor’s order that says you need inpatient hospital care to treat your illness or injury, and you are admitted to inpatient hospital care.
- The hospital accepts Medicare insurance.
- In some cases, the hospital’s Utilization Review Committee (URC) approves your stay while you’re in the hospital.
What Isn’t Covered by Part A
Private-duty nursing, a private room (unless medically necessary), television and phone in your room, and personal care items such as razors or slipper socks are all at additional cost. This is not a complete list, and you should ask questions to understand the care you’ll receive and whether your Medicare plan covers certain services. Asking questions will help you save on out-of-pocket costs.
Skilled Nursing Care Coverage & Short-term Nursing Home Care
Skilled nursing care is nursing or therapy care that is performed by nursing professionals or technical personnel. It’s health care given when you need skilled nursing or therapy to treat, manage, or observe your condition and evaluate your care. Limited care in a Skilled Nursing Facility (SNF) is covered by Part A.
Your skilled nursing care is Medicare-eligible when you:
- You are enrolled in Part A.
- Have days left in your benefit period to use. The benefit period begins when you’re admitted to a Skilled Nursing Facility (SNF) or an inpatient hospital. It ends when you haven’t had inpatient or skilled nursing care for 60 consecutive days.
- Have 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.
- Your doctor has decided that you require daily skilled care.
- The care received must be given by, or under the supervision of, a skilled nursing or therapy staff person at an SNF Medicare-certified facility.
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.
The purpose of the skilled services is for a medical condition that’s either:
- A hospital-related medical condition treated during your qualifying three-day inpatient hospital stay, even if the reason you were admitted to the hospital is unrelated.
- A condition that started while you were getting care in an SNF for a hospital-related medical condition.
What’s Covered While At A Skilled Nursing Facility?
The following Medicare-covered services include, but are not limited to:
- A semi-private room that you share with other patients, and meals.
- Part-time skilled nursing care.
- Physical therapy, occupational therapy, and speech-language pathology services if they are needed to meet your health goal.
- Medical social services and dietary counseling.
- Medications while in Skilled Nursing Facility (SNF) care.
- Medical supplies and equipment used in the facility and swing bed services while in SNF care.
- Ambulance transportation to the nearest supplier of needed services that are available at the SNF, but only when other transportation endangers your health.
Long-Term Nursing Home Care is Not Covered
Medicare will not cover long-term nursing home care that’s custodial/daily living in nature—if it’s the only care needed. Custodial care means that you’re receiving support for everyday living. This includes tasks such as bathing, dressing, using the restroom, eating, and other personal needs that couldn’t be done without the help of a skilled nurse.
Home Health Care Benefits
Home health care provides a range of health care services in your home for an illness or injury. Services could include wound care, patient and caregiver education, intravenous or nutrition therapy, injections, or monitoring serious illness and unstable health.
Home health care can help you regain your independence, become as self-sufficient as possible, maintain your current condition or level of function, get better, or slow decline.
It is also usually less expensive, more convenient, and as effective as the care you receive in a hospital or Skilled Nursing Facility (SNF). Usually, a home health care agency coordinates the care your doctor orders for you.
Your home health care is Medicare-eligible when you:
- You have Medicare Part A.
- You are under the care of a doctor and are receiving services under a plan of care created and reviewed regularly by a doctor.
- Your doctor must certify that you need intermittent skilled nursing care—such as blood drawn. Or physical therapy, speech-language pathology, or continued occupational therapy. Read the additional criteria for when you’re eligible for these services and when Medicare covers them.
- The home health agency caring for you is Medicare-certified.
- A doctor certifies that you are homebound. This means that you cannot leave your home without substantial effort. Or it is medically unadvised that you leave home without the help of another person, transportation, or special equipment.
If you require more than part-time or intermittent skilled nursing care, you are not eligible for the home health benefit. Although your doctor certifies that you are homebound, you may leave home for medical treatment or short, infrequent absences for non-medical reasons. That could include attending religious services, for example. You can still receive home health care if you attend adult daycare.
What Home Health Care is Covered?
Your Medicare Part A (hospital insurance) or Medicare Part B covers eligible home health services. This includes part-time or intermittent skilled nursing care or home health aide services, physical and occupational therapy, speech-language pathology services, medical social services, and injectible osteoporosis drugs for women, among others. You should ask whether the care that you need will be covered by Part A.
What Isn’t Covered by Part A
Medicare Part A doesn’t cover 24-hour-a-day care in your home or meals delivered. Nor does it pay for homemaker services or custodial care when these are the only care you need. These services include shopping, cleaning, laundry, bathing, dressing, and using the restroom. You may incur a 20% cost of the Medicare-approved amount for durable medical equipment.
Before starting your home health care, the home health agency should let you know what isn’t covered by Medicare and any out-of-pocket costs. This should be provided when they speak with you, but also in writing. Before any home health care begins, the agency should also provide a notice called an Advance Beneficiary Notice (ABN) that outlines the services and supplies that Medicare doesn’t cover.
Hospice Care Coverage
If your doctor certified that you have a terminal illness with approximately six months or less to live, you may be eligible for hospice care coverage under Medicare. Hospice care is not for curing your disease but for relieving your pain and making you as comfortable as possible.
Your hospice care is Medicare-eligible when:
- You are enrolled in Medicare Part A.
- A hospice doctor or your doctor certifies that you’re terminally ill with a life expectancy of 6 months or less.
- You agree to comfort care instead of care to cure your disease.
- You’ve signed a statement choosing hospice care instead of other benefits Medicare covers to treat your terminal illness and related conditions.
- You receive hospice care from a Medicare-approved facility, which could include your home or another facility where you live—like a nursing home.
What Hospice Care is Covered?
The following Medicare-covered services may include, but are not limited to:
- All items and services required for pain relief and symptom management, including pain relief medications.
- Medical, nursing, social services, as well as spiritual and grief counseling for you and your family.
- Durable medical equipment and medical supplies for pain relief and symptom management.
- Hospice aide and homemaker services.
- Physical, occupational therapy, and dietary counseling.
- Short-term inpatient care if necessary for managing pain or symptoms.
- Short-term respite care.
Even though you need to give up curative treatments to receive Medicare coverage for your terminal illness, you have the right to stop hospice care at any time. If you are considering going back to curative treatments, talk to your doctor.
What Isn’t Covered by Part A
You should check with your hospice team before receiving any of the following services or you may be required to pay the entire cost:
- Treatment or prescription drugs to cure your terminal illness and/or related conditions.
- Care from any hospice provider that wasn’t set up by the hospice medical team.
- Room and board in your home, at a nursing home, or a hospice inpatient facility.
- Care you get as a hospital outpatient, like an emergency room, care you get as a hospital inpatient, or ambulance transportation unless it’s arranged by your hospice team or is unrelated to your terminal illness and related conditions.
There may come a time when you’ll be in need of the hospital care traditionally covered by Medicare Plan A. But there are exclusions to that coverage. Call Connie Health to ensure that you’re on the right plan for your health and budget: (623) 223-8884.
Learn more about Medicare
Visit our Medicare Resource Center which provides helpful articles on everything you need to know about Medicare.