Understanding Medicare Part A

Medicare Hospital Insurance Benefits

Medicare Part A

Medicare has four parts, or programs that provide coverage for different health-related services. Understanding how Medicare works may help you choose the Medicare options that best fit your needs.

Medicare Part A, also known as the Hospital Insurance program, helps cover the costs of:

Who is Eligible for Medicare Part A?

If you are 65 or older, you are automatically eligible for Medicare Part A. Your Medicare Part A coverage starts on the first day of the month you turn 65. You also should receive your Medicare card in the mail 3 months before your 65th birthday.

If you are under 65 you are eligible to receive Part A benefits under the following circumstances:

  • You have been receiving Social Security Disability Insurance for more than two years – you should get your Medicare card in the mail prior to your 25th month of disability.
  • You have permanent kidney failure (end-stage renal disease, or ESRD) requiring ongoing dialysis or a kidney transplant. Special rules apply for people with ESRD.
  • You have been diagnosed with amyotrophic lateral sclerosis (Lou Gehrig’s disease). If you have ALS, you get Part A the month your disability benefits begin.

Do I Have to Pay for Medicare Part A?

If you are eligible for Medicare you will not have to pay a monthly premium for Part A if you or your spouse paid Medicare payroll taxes while working.

If you and your spouse did not work or did not pay enough Medicare payroll taxes you may not be eligible for premium-free Part A. However, you may be able to purchase Part A by paying a monthly premium, which is up to $461 in 2010. You should contact your local Social Security office 3 months before your 65th birthday to sign up.

If you choose to buy Medicare Part A, you also will may have to enroll in and pay a premium for Medicare Part B. If your income is limited and you cannot afford the monthly premiums for Part A and/or Part B, your state may have a program to help. For information view the brochure Get Help With Your Medicare Costs and visit the State Health Insurance Assistance Program (SHIP) site for information about free counseling in your state.

What does Medicare Part A Cover?

Hospital Stays
Covered services include a semi-private room, meals, general nursing care, medications, and other hospital services and supplies. Medicare does not cover private-duty nursing, the cost of a telephone or television in your hospital room, personal care items such as toiletries, or a private room, unless it is necessary for your treatment.

You will have to pay towards your care and Medicare does have some limits on hospital coverage.

For each benefit period in 2010 you pay:

  • A total deductible of $1,100 for a hospital stay of 1-60 days.
  • $275 per day for days 61-90 of a hospital stay.
  • $550 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).
  • All costs for each day beyond 150 days.

Additionally, inpatient mental health care in a psychiatric hospital limited to 190 days for your lifetime.

A Dr. Mike definition:A benefit period (or a spell of illness) begins the day you go into a hospital (or skilled nursing facility, or SNF) and ends when you have not received any inpatient care (in the hospital or SNF) for 60 days in a row. You will have to pay the inpatient deductible for every benefit period.

Skilled Nursing Facility
Covered services include a semi-private room, meals, skilled nursing and rehabilitative services, and related supplies. Your stay in a SNF will be covered by Medicare only after a 3-day minimum inpatient hospital stay for a related illness or injury.

For example, if you were hospitalized for a stroke for one week, a skilled nursing facility stay for rehabilitation would be covered.

You have no costs for the first 20 days in the SNF, you will then have to pay (in 2010) $137.50 for days 21 through 100 and all costs for each day after day 100. These apply to each benefit period.

Home Health Services
To receive coverage of home health services from Medicare, you must be homebound (meaning that leaving home is a major effort), your doctor must order your care, and the services must be provided by a Medicare-certified home health agency.

Coverage for home health care includes only medically necessary, part-time services such as skilled nursing care, home health aide, physical or occupational therapy, speech-language pathology, and medical social services. It also includes durable medical equipment (such as wheelchairs, hospital beds, walkers, oxygen) and medical supplies for use at home.

You will have no costs related to the actual services provided in your home. However, you will have to pay a coinsurance of 20% of the Medicare-approved amount for any durable equipment your doctor orders.

Hospice Care
Hospice care is for people with a terminal illness who are expected to live six months or less. Coverage includes medication for relief of pain, and control of other symptoms; medical, nursing, and social services; and grief counseling. The services must be provided by a Medicare-approved hospice.

Medicare also will cover inpatient respite care, which is care you get so that your usual caregiver can rest. Medicare will continue to cover your hospice care as long as your hospice physician or the medical director of the hospice recertifies that you are terminally ill.

Although there is no cost for hospice services, you will have a copayment of $5.00 for each outpatient prescription and you will be charged 5% of the Medicare-approved amount for inpatient respite care.

Should I Enroll in a Medigap Plan?

While Medicare Part A will most likely pay for most of your hospital and skilled nursing facility expenses, you still will have some out-of-pocket costs. So, you may want to consider a Medigap plan to help pay your out-of-pocket costs such as hospital deductibles, coinsurance charges, and copayments. If you enroll in a Medicare Advantage plan, some of these costs may also be covered.

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