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Medicare Part A is the portion of Medicare that covers hospital or skilled nursing facility stays. The general rule is that Medicare Part A beneficiaries receive insurance coverage for hospital expenses that doctors determine to be necessary for inpatient care.
For example, the rules accept a semi-private room, nutritionally balanced meals, skilled nurse’s care, and medicines that comprise a necessary part of the inpatient care.
Inpatient care under Medicare Part A is also provided by mental health care providers, rehabilitation facilities, long-term care hospitals, acute care hospitals, and care for those patients chosen to participate in clinical studies.
The general rule is that Part A beneficiaries receive insurance coverage for hospital expenses that medical doctors determine to be necessary for inpatient care.
For example, the rules accept a semi-private room, nutritionally balanced meals, skilled nurse’s care, and medicines that comprise a necessary part of the inpatient care.
Inpatient care under Part A is also provided by mental health care providers, rehabilitation facilities, long-term care hospitals, acute care hospitals, and care for those patients chosen to participate in clinical studies.
Medicare Part A hospital insurance does not cover the costs for a private room unless determined to be medically necessary. It does not cover private-duty nursing.
This restrictive policy on offering room devices may be a source of consumer dissatisfaction; it may also be a source of medical fact. Offering home comforts might contribute to medical care objectives in some measurable way. Patient mood and outlook may affect healing in quantifiable measurements.
While patients may need many items to carry on as normal, Medicare Part A excludes personal care items and usual luxuries like telephone and television charges. These normally present items and services are not included under Medicare Part A.
In five broad areas, Medicare Part A coverage includes the below-itemized coverage categories:
Medicare Part A covers a stay in a nursing facility for qualified covered members. To qualify for skilled nursing facility coverage, one must first have an inpatient stay in a hospital for a related illness, injury, or condition.
A qualifying hospital stay must be for a minimum of three days excluding the day of discharge. The rules are precise on the qualifying stay; times spent under observation as an outpatient do not count towards the three-day minimum.
The three-day minimum begins on the day of admission, and it must end the day before discharge. Patients must spend a minimum of three days inpatient status not counting the day of discharge.
Under Part A, nursing care must be skilled and not merely custodial. The skilled nursing care must be provided at a Medicare-certified facility, and it must be part of the illness or conditions in the prior hospitalization. Medicare-covered skilled nursing care includes the below–listed skilled services and others:
A doctor must certify that the patient needs daily skilled care that they cannot receive at home. For example, intravenous drugs or physical therapy would not be available at home without skilled nurse’s care. Part A does not cover long-term care or personal care when that is the only care needed.
A frequent basis for using a skilled nursing facility is some follow-on care from the original hospitalization. It could be a physical therapy goal such as walking and gaining a degree of independence.
The nursing skills involved could be multi-disciplinary and include routine or daily assessments. When following a doctor’s orders, these assessments offer a record of efforts to meet the treatment goals and the results.
Medicare Part A benefits cover home health services when found medically necessary by the attending physician. These are among the limited circumstances when Part A covers medical services at home.
Part A covers the entire cost of covered home health care services. Durable equipment has a separate status. If doctor orders needed durable medical equipment, the costs are covered by Medicare Part B.
The policyholder may have to co-pay 20 percent of the Medicare-approved amount. The home health care must be provided by a Medicare-certified home health agency. A doctor must certify that the patient is technically home-bound.
Medicare standards agree that a patient is homebound if the following two items are true:
When ordered by the doctor as medically necessary, Part A covers services in the home. They include these listed home health care services:
If a treating doctor has determined a terminally ill patient with an estimated six months or less to live, the patient may be eligible for hospice coverage. In hospice care, the treatment focus shifts to comfort rather than to curing disease. The goal of hospice care is to relieve pain and make the patient as comfortable as possible.
To qualify for Medicare-covered hospice care, a patient must meet all of the below-specified conditions to qualify for Medicare A-Hospice Care:
The patient and Medicare agree to the following guidelines.
Part A hospice care is usually provided and received in the patient’s home. The idea is to promote comfort and familiar environment.
Although the patient surrenders rights to curative treatments for the terminal disease in exchange for hospice care, the decision is not irrevocable. Each patient reserves the right to cease hospice care at any time. Medicare advises each patient to consult with their treating doctor about going back to curative treatments.
Medicare may from time to time assume payment for costs that it does not normally undertake to pay. This may include spiritual guidance or grief management. Part A covers hospital room and board when the medical care providers order short-term inpatient stays for pain management or to manage other symptoms.
The range of services provided shall be as needed. It may include but is not limited to the specified equipment, services, and medical personnel set out below:
In 2018, Part A can cost as much as $411 per month. Most recipients do not have to pay a monthly premium because they fall into a category called premium-free Part A.
At age 65, persons qualify for premium-free Part A if they meet one or more of the below-listed tests.
Persons under age 65 get Premium-free Part A if they meet one of the below-listed categories.
As a practice, if you choose to buy Part A, you must also have Medicare Part B (Medical Insurance). In these cases, recipients pay a single monthly premium for both services.
In general, people age 65 or older are eligible for Medicare Part A if they have one or more of the below-described factors:
The law provides an initial enrollment period of seven months. Those who fail to enroll in the seven-month period around the 65th birthday may have to wait until a general or special enrollment period. Some may have to pay a late enrollment penalty. The enrollment period runs from three months before the 65th birthday month to three months after the 65th birthday month.
Outside of the seven-month initial enrollment period surrounding the applicant’s 65th birthday month, there is a general enrollment period in which any eligible person may apply. The general enrollment period for Medicare runs from January 1 through March 31 of each calendar year. However, insurance coverage for those enrolled during general enrollment period does not begin until the First Day of the following July.
There is a special enrollment period for Part A that is based on life circumstances. Called the special enrollment period, this phase allows continuation of coverage when individuals lose coverage that they had through an employer.
The SEP affects those enrolled through a spouse or directly with an employer or union-sponsored group hospital insurance by providing another path to coverage.
Those who lost coverage through an employer or labor organization or who were on a mission serving as volunteers in a foreign country can enroll immediately. They can also enroll during a special enrollment period.
The SEP begins in the month after the loss of employer or union-sponsored coverage. The SEP starts the month after the previous coverage ends; it runs for eight consecutive months.
For some persons, the loss of coverage occurs during what would have been their Initial Enrollment Period (IEP). These applicants can simply proceed into their initial enrollment period for Medicare part A.
Those who purchase a Medicare A premium do not have to pay the late enrollment penalty if any when qualified for an SEP. Those that qualify for an SEP get coverage the first month after enrollment. They usually get a Medicare card within thirty days of enrollment.
Medicare A works with Medicare Part B to combine hospital insurance with medical insurance. Insurance coverage from private providers can fill gaps in Medicare, and offer extensive coverage for prescriptions.
Particular policies can upgrade certain options for hospitals and facilities such as private rooms and extras.
Remember the Affordable Care Act made changes across health insurance, which expanded benefits under Medicare Part A such as the extensive amount of no charge testing and examinations to detect early stages of serious diseases.
Payment priority is the key issue so that consumers can avoid as many copayments and uncovered charges as possible. Sometimes Medicare is first in payment priority, and it pays up to its limit. Any balance remaining may he to be paid by the secondary coverage.
The precise rules, interpretations, and exceptions come from three sources of authority. The Congress, which creates national policies, the Centers for Medicare, which issues program rules, and the local rules developed by the claims process and review of program actions.
This three-part source of rules and precedents helps keep the program flexible and up to date. Medical procedures, standards, and technology change on a constant basis. Innovation is a key concept in medical science. The local experiences of the review systems contribute to positive trends and advances.