What is Medicare Part A?
Medicare Part A is insurance coverage that helps pay for costs associated with hospital admission or a stay in a skilled nursing facility. Medicare Part A, along with Medicare Part B, is part of Original Medicare.
Original Medicare (frequently called fee-for-service or traditional Medicare) is part of the federal Medicare program. Medicare consists of four parts:
- Medicare Part A — hospital care
- Medicare Part B — doctor and medical care
- Medicare Part C — a different way to receive Medicare Part A and Medicare Part B coverage (Medicare Part C is also known as Medicare Advantage)
- Medicare Part D — prescription drug coverage
Medicare Advantage Plans replace Original Medicare. If you have Medicare Advantage, you cannot have Original Medicare. Advantage plans typically have network and specialist restrictions, but they also often include prescription drug coverage.
What does Medicare Part A Cover?
Medicare Part A health insurance covers a range of services. Those services include:
- Inpatient hospital care
- Skilled nursing facility care (you must be in the hospital at least three days before Medicare Part A pays for skilled nursing facility care)
- Hospice care
- Home health services (within limits)
- Short-term nursing home care
- Inpatient mental health care in a psychiatric facility (limited to 190 lifetime days)
Medicare Part A covers inpatient hospital care you receive in the following facilities:
- Critical access hospitals
- Acute care hospitals
- Long-term care hospitals
- Inpatient rehab centers
- Mental health facility
- Inpatient care delivered as part of a clinical research study
What is the Deductible for Medicare Part A?
For 2019, the deductible for Medicare Part A is $1,364 for each benefit period. A benefit period starts the day you are admitted to the hospital, and it ends when you have been out of the hospital or skilled nursing facility for 60 consecutive days.
You can have more than one benefit period in a calendar year. If you have an admission in February, you pay a $1,364 deductible for that benefit period. If you are admitted again in September, you will pay another $1,364 deductible.
How does Medicare Part A cover inpatient hospital care?
Medicare Part A hospital insurance covers healthcare costs you acquire during a hospital admission, but staying overnight in a hospital bed does not necessarily mean you are admitted. It is essential that you understand the definition of hospital admission because if you are not formally admitted, Part A will not pay your hospital costs.
Instead, payment will come under Medicare Part B, which covers outpatient services. Your cost-share amount is different under Part B compared to Part A.Typically, you pay more for services under Part B.
Under Part A, you pay a $1,364 deductible for each admission, and then Medicare Part A pays the rest of your hospital costs for the first 60 days.
Under Medicare Part B, Medicare pays 80% of approved services after you meet your calendar-year deductible. You are responsible for the 20% coinsurance and copayments for each service provided. You are also responsible for any medication costs.
For Part A to cover your hospital costs, you must meet the following conditions:
- A doctor must write an official order stating you need inpatient care to treat your condition.
- The hospital participates in Medicare.
- In some situations, the hospital’s Utilization Review Committee can approve your stay.
Your Medicare Part A benefits do not cover the entire cost of hospital services. You must meet your $1,364 deductible for each benefit period. You also have a coinsurance responsibility each time:
- No coinsurance days 1-60
- $341 coinsurance each day for days 61-90
- $682 coinsurance days 91and beyond for up to 60 lifetime reserve days
- Entire cost after you have used your 60 lifetime reserve days
Once you meet the definition of being admitted, Medicare Part A covers a variety of services. Examples of inpatient hospital care services that Medicare Part A covers include:
- Semi-private room
- Lab tests
- Operating and recovery room
- Nursing services
- Special-unit care such as ICU or CCU
- Blood for transfusion after the first three pints (you pay for the first three pints if a free blood bank is not available)
Medicare Part A hospital insurance does not cover physician fees, even if you are an inpatient in the hospital. Surgeon, anesthesiologist, and radiologist services are among the physician fees you might receive during a hospital stay. Medicare Part B covers these fees.
There are other inpatient services you might receive that Part A does not cover:
- Private hospital room unless medically necessary
- Private-duty nursing
- Personal items such as shampoo, toothbrush, or razor
- Telephone or television charges
- The first three pints of blood for a transfusion (if the hospital has to buy the blood for you)
How does Medicare Part A cover skilled nursing home care?
Medicare Part A medical insurance pays for care in a skilled nursing facility (SNF) after you have a qualifying inpatient stay in a hospital. Medicare defines a qualifying inpatient stay as admission for at least three days in a row. If you do not meet the definition of an inpatient stay, Medicare Part A will not pay for SNF care.
In addition to a qualifying inpatient stay, you must also meet the following conditions for Part A to pay for skilled care:
- You have days left in your benefit period.
- Your doctor states that you need skilled care.
- Skilled therapy or nursing staff provide or supervise the care.
- You receive services in a Medicare-certified SNF.
- You need skilled services because of a hospital-related medical condition or a condition that began while you were receiving SNF care.
You will have a cost-share responsibility for skilled nursing care under Part A:
- You pay nothing days 1-20
- You pay $170.50 coinsurance days 21-100
- You are responsible for all costs from day 101 onward
How does Medicare Part A cover hospice care?
Medicare Part A hospital insurance will pay for hospice care if you meet these criteria:
- Your family doctor or hospice doctor certifies that your life expectancy is six months or less.
- You opt for palliative care (comfort care) rather than medical treatment.
- You sign a statement choosing hospice care rather than other Medicare services to treat your terminal illness.
Your cost-sharing amounts include:
- $5 per prescription for pain and symptom management
- 20% of the cost of durable medical equipment used at home
- 5% of the cost of inpatient respite care
Hospice services covered by Part A:
- Doctor and nursing services
- Medical equipment and supplies
- Aide and homemaker services
- Prescriptions for pain and symptom management
- Short-term inpatient care for pain and symptom management
- Physical and occupational therapy
- Speech-language and social work services
- Dietary counseling
- Grief counseling (for you and your family)
- Occasional short-term respite care (up to five days each time)
How does Medicare Part A cover Home Health Care?
Your Part A benefits include coverage for some home health services. You qualify for Medicare Part A health insurance home health care benefits if:
- You are under a doctor’s care.
- A doctor certifies that services are medically necessary.
- A doctor certifies that you are homebound.
- A Medicare-approved home health agency provides the care.
Home health services that Part A covers include the following:
- Skilled nursing (part-time or intermittent)
- Physical or occupational therapy
- Speech-language pathology services
- Social services
- Home health aide (personal hands-on care, occasional or part-time)
Your cost-share includes:
- 20% of Medicare’s approved amount for durable medical equipment
Eligibility: Who Qualifies for Medicare Part A?
Most individuals are automatically eligible for Medicare Part A health insurance at age 65 if they are collecting retirement benefits from one of the following:
- Social Security Administration
- Railroad Retirement Board
You may qualify for Part A before age 65 if you have one of the following:
- A disability
- End-stage renal disease (ESRD)
- Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
If you qualify for Part A based on Social Security (SS) or Railroad Retirement (RR) benefits, disability, or ESRD or ALS, you will not pay a monthly premium for Part A benefits (premium-free Part A).
If you do not qualify for Medicare Part A under one of these situations, you will pay a monthly premium for Part A (premium Part A). Your premium amount is based on how many years you or your spouse worked. For 2019, the premium is $240 if you or your spouse worked between 7.5 and 10 years. The premium is $437 if you or your spouse worked for less than 7.5 years.
To be eligible for premium Part A, you must:
- Be 65 or older
- Be either a U.S. citizen or a legal permanent resident living in the U.S. at least five continuous years
- Apply by contacting the Social Security Administration
- Enroll in or already be enrolled in Medicare Part B
- Enroll during a valid enrollment period
If you are entitled to premium-free Medicare Part A, you can enroll any time after you are eligible. If you want premium Part A, you have three times during which you can enroll:
- Initial enrollment period
- General enrollment period
- Special enrollment period
Initial Enrollment in Medicare Part A?
Most individuals who qualify for premium-free Medicare Part A hospital insurance are automatically enrolled in Part A. Coverage begins based on how you qualify:
- You are receiving SS or RR benefits: You are automatically enrolled. Coverage begins the first day of the month in which you turn 65. Your Medicare card typically arrives about three months before you turn 65.
- You qualify through disability: You are automatically enrolled. Coverage starts the 25th month after you begin receiving SS benefits. Your Medicare card typically arrives about three months before coverage begins.
- You qualify through ALS: You are automatically enrolled. Coverage begins the same month you start receiving SS benefits. Your Medicare card arrives about 30 days after you sign up to receive disability benefits.
- You qualify through ESRD: You have to apply. Enrollment and coverage dates depend on whether you have group health coverage through an employer, undergo home dialysis, or have dialysis at a facility. Feel free to call one of our agents to discuss your situation.
- You want premium Medicare Part A: Your IEP is the seven months that start three months before your 65th birthday, includes your birthday month, and ends three months after your 65th birthday. If you do not join during your IEP, you will pay a late enrollment penalty. Start of coverage depends on when you enrolled during your IEP.
General Enrollment Period for Medicare Part A
If you did not enroll in Medicare Part A when you were first eligible, you can sign up during the General Enrollment Period. The GEP runs from Jan. 1 to Mar. 31 of each year. Your Medicare Part A coverage will begin July 1. Your Medicare card will typically arrive three months before coverage begins.
If you do not qualify for premium-free Medicare Part A and did not enroll in premium Medicare Part A when you first qualified, you will pay a 10% higher monthly premium. You will have to pay this higher premium for twice the length of time you could have been enrolled but were not. For example, if you sign up two years after you were eligible for premium Part A, you will pay the higher premium for four years. This higher premium is waived if you meet the conditions of a special enrollment period.
Special Enrollment Period for Medicare Part A
If you delayed enrolling in premium Medicare Part A because you had group coverage through an employer, you can join during a special enrollment period without penalty. Your SEP is an eight-month period that begins the month that either your employment ends or your group coverage ends, whichever comes first. You can also enroll in Part A while you still have group health coverage.
If you receive premium-free Medicare Part A benefits, you cannot voluntarily stop your coverage. Your coverage ends either upon your death or if you no longer qualify for SS or RR benefits. Premium Medicare Part A benefits can be terminated for several reasons:
- Failure to pay your premiums
- Part A entitlement ends for those under age 65 with ESRD or disability
If you choose your Part A and Part B health coverage through Original Medicare and want coverage for your outpatient medications, you will have to buy a separate Medicare Part D prescription drug plan.
Medicare Supplement plans help cover your deductible and coinsurance costs with Medicare Part A. If you are interested in a Medicare Part D or Medicare Supplement plan quote, give one of our licensed agents a call. We are happy to help you find coverage that fits your unique situation.