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, and have been legally present in the U.S. for at least five years, you are automatically eligible for Medicare Part A. And if you or your spouse worked at least ten years in a job where you paid Medicare taxes (part of the FICA taxes), you'll receive Medicare Part A without having to pay any premiums.

Your Medicare Part A coverage starts on the first day of the month you turn 65, as long as you apply for coverage before that month. If you're already receiving Social Security retirement benefits or Railroad Retirement Board benefits, you'll be automatically enrolled in Medicare as of the month you turn 65, without having to manually enroll. In that case, you 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, and the coverage start date depends in part on whether you enroll in a home dialysis program.
  • 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 worked and paid Medicare payroll taxes for at least ten years.

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 $458 in 2020 (the premium is lower, at $252/month, if you have at least 7.5 years of work history but less than a full ten years/40 quarters). You should contact your local Social Security office up to three months before your 65th birthday to sign up.

If you choose to buy Medicare Part A, you also have the opportunity to enroll in Medicare Part B, which has a premium for all enrollees (in most cases, it's $144.60/month in 2020).

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.

Medicare does have some limits on hospital coverage. And you will have to pay a fairly modest portion of the cost of your care. But those out-of-pocket costs can be covered in part or in full by supplemental coverage obtained from an employer's plan, Medicaid, or a Medigap plan.

Medicare Part A differs from most commercial health insurance plans in that the deductible is based on a benefit period, rather than the calendar year. So depending on how much treatment you need and how it's spread out through the year, it's possible that you may have to pay the deductible more than once in a year. But it's also possible to only have one deductible even when you have a hospitalization that spans two calendar years (in that scenario with most commercial insurance plans, you'd pay two deductibles).

For each benefit period in 2020 you pay:

  • A total deductible of $1,408 for a hospital stay of 1-60 days.
  • $352 per day for days 61-90 of a hospital stay.
  • $704 per day for days 91-150 of a hospital stay (Lifetime Reserve Days; you have a maximum of 60 of these over your lifetime; they do not reset for each benefit period the way the other day counts do).
  • All costs for each day in the hospital once your lifetime reserve days are used up—unless you have a Medigap plan that pays for additional hospital coverage.

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

A Dr. Mike definition:A benefit period 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 Original Medicare only after a three-day minimum inpatient hospital stay for a related illness or injury (Medicare Advantage plans have the option to waive the three-day hospital stay requirement).

For example, if you were hospitalized for a stroke for one week, a skilled nursing facility stay for rehabilitation would be covered. But if you were only hospitalized for two days, your Original Medicare would not cover a subsequent skilled nursing facility stay. And if your hospitalization was classified as observation instead of inpatient care, you would not qualify for skilled nursing facility care after leaving the hospital.

You have no costs for the first 20 days in the SNF, you will then have to pay (in 2020) $176 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. Custodial care and assistance with activities of daily living (bathing, dressing, eating, etc.) are not covered by Medicare.

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 program.

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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Article Sources

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  1. Medicare.gov. Getting started with Medicare.

  2. Medicare.gov. Sign up/Change plans.

  3. Medicare.gov. Signing up for Medicare if you have ESRD.

  4. Medicare.gov. Part A costs.

  5. Medicare.gov. Part B costs.

  6. Medicare.gov. Is my test, item, or service covered? Inpatient hospital care.

  7. Medicare.gov. Is my test, item, or service covered? Inpatient mental health care.

  8. Medicare.gov. Is my test, item, or service covered? Skilled nursing facility (SNF) care.

  9. Medicare.gov. Is my test, item, or service covered? Home Health Services.