What is Medicare Part A?

What are the limitations of Medicare Part A?

Medicare Part A hospital insurance does not cover the costs for a private room unless determined to be medically necessary. Likewise, it does not cover private-duty nursing.

While patients may desire many comfort items to maintain a sense of normalcy during their time admitted to the hospital, Medicare Part A excludes personal care items and domestic luxuries.

Thus, the focus of Part A is the medical attention you receive during a hospital stay you need.

To illustrate, Medicare Part A excludes paying for items and services normally present at home like telephone and television, internet access, or commodities other than needed for basic hygiene.

What does Medicare Part A help cover?

In five broad areas, Medicare Part A covers the below-itemized coverage categories:

• Hospital care for inpatient services
• Limited home health services with a doctor’s determination of medical necessity
• Skilled nursing facility care, provided that skilled care is required
• Hospice for end of life situations, which can also cover services for comfort and dignity not normally covered under Part A. Hospice can stop whenever the patient wishes to return to normal treatment situations
• Nursing Home Care when needs exceed more than custodial care 

Medicare Part A – Nursing Home Coverage

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 last a minimum of three days, excluding the day of discharge. The rules are precise on the qualifying stay; time spent under observation as an outpatient does not count towards the three-day minimum.

Does Medicare cover nursing homes?

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 directly treat the illness or condition causing the prior hospitalization.

Medicare-covered skilled nursing care includes the below–listed skilled services and others:

• Treatment in a semi-private room
• Serving nutritional meals that are balanced
• Skilled nursing services such as monitoring conditions and maintaining records
• Rehabilitation services considered medically necessary to treat an illness or condition
• Providing medical social services such as wellness activities and health education
• Controls over medications received while in skilled care
• Use and care for medical supplies and equipment used in skilled care
• Arranging proper ambulance transportation to nearest provider if needed services are  unavailable at the skilled nursing facility
• Dietary analysis and counseling

What qualifies a patient for skilled nursing care?

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.

Accordingly, Part A does not cover personal care when that is the only type of care needed. Personal care involves assistance with tasks like bathing, dressing, laundry, or using the bathroom.

Follow-on care from the original hospitalization is a frequent basis for using a skilled nursing facility

Skilled nursing facility (SNF) care involves assessment of what type of services are needed, and health goals of the patient. For example, this could be a physical therapy goal, such as walking a certain distance or climbing stairs in order to regain a degree of physical independence.

The nursing skills could involve multi-disciplinary staff and will 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 of those efforts.

As a result, these assessments allow patients to continue being covered for up to 100 days in a row under SNF care. Beyond the 100th day, their benefit period ends, meaning patients are responsible for all costs. A benefit period measures use of these types of facilities.

Moreover, once 60 days have passed from the last time a patient got care from a hospital or nursing facility, they get a new benefit period.

Does Medicare cover home health care?

Medicare Part A covers the entire cost of home health services when found medically necessary by an attending physician.

Accordingly, home health care must be provided by a Medicare-certified home health agency.

First, a doctor must certify that the patient is technically home-bound, currently seeking treatment, and that needed services can only be performed safely and effectively by qualified therapists.

Medicare standards agree that a patient is homebound if the following two items are true:

• Under normal circumstances, one cannot leave home unassisted and attempting to do so would require a difficult level of effort.
• It is medically risky to leave home without the help of another person, special transportation, or special equipment

Durable medical equipment (DME) has a separate status. If a doctor orders durable medical equipment, the costs are instead covered by Medicare Part B.

With that said, the policyholder may have to pay a 20 percent portion of what is considered the equipment’s Medicare-approved amount; an amount that is often less than the amount normally charged by the supplier for that equipment. 

Medicare Part A – Home Health Care Benefits

When ordered by the doctor as medically necessary, Part A covers services in the home.

They include these listed home health care services:

• Skilled nursing care on a part-time, intermittent, or as needed basis
• Physical therapy as key to recovery
• Speech-language pathology services that only a qualified therapist could perform safely at home
• Occupational therapy that only a qualified professional could perform safely at home
• Certain types of medical social services that promote healing and recovery
• Part-time or intermittent home health aide services

Hospice Coverage

If a treating doctor has determined the patient to be terminally ill, the patient becomes eligible for hospice coverage. The phrase ‘terminally ill’ defines having an estimated six months or less to live.

In hospice care, the treatment focus shifts to comfort rather than to curing disease.

This is called palliative care, the goal of which is to relieve pain and make the patient as comfortable as possible instead of seeking treatment to cure the related conditions.

Medicare agrees to cover comfort-focused treatment for the terminal illness, along with treatment and drugs related to controlling the symptoms of that illness.

Part A hospice care is usually provided and received in the patient’s home. The idea is to promote comfort by remaining in a familiar environment.

Consistently, to qualify for Medicare-covered hospice care, a patient must meet all of the below-specified conditions to qualify for Medicare A-Hospice Care:

• Successful enrollment in Part A
• Medical certification of terminal illness with an estimated life expectancy of six months or less
• Formally agree to release medical providers from responsibility for treating the terminal condition
• Only accept hospice care from a Medicare-approved facility.

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.

Of course, Medicare advises each patient to consult with their treating doctor about going back to curative treatments.

What can be expected from hospice care?

Upon entering the care of a Medicare-certified hospice team, the patient’s relief is emphasized.

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.

It should be noted that 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.

Additionally, 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.

What does hospice care cover?

The range of services provided must be determined as medically necessary.

Services may include but are not limited to the equipment, services, and medical personnel set out below:

• Doctor services – medical services from doctors to alleviate pain and discomfort and to advise the patient.
• Nursing care – skilled nurses to provide services such as delivering medications and pain relieving procedures.
• Pain relief medications – pain relief medications and procedures as directed by the hospice medical care providers.
• Comfort and support medical treatment –  social services, hospice aide services, dietary counseling, spiritual and grief counseling, and homemaker services.
• Equipment and therapy – durable medical equipment, medical supplies, and physical and occupational therapy.
• Short-term inpatient care – short-term inpatient care if considered medically necessary for pain management or control of other symptoms.
• Short-term respite care – short-term respite care when medically advisable by the hospice provider to manage pain and alleviate symptoms for up to 5 days at a time in order to give your usual caregiver (like a family member or friend) a chance to rest. This can be covered more than once, but is offered only on an occasional basis

If you start hospice care on or after October 1, 2020, you can ask your hospice provider for a list of items, services, and drugs that they’ve determined aren’t related to your terminal illness and related conditions.

This list must include the reasons they made that determination. Your hospice provider is also required to give this list to your non-hospice providers or Medicare if requested.

How much does Part A cost?

In 2021, Part A can cost as much as $471 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 criteria:

• Pre-qualified for federal retirement benefits
• Eligible, but haven’t yet filed for federal benefits, such as Social Security Income
• Applicant or spouse had qualified government employment

Persons under age 65 get Premium-free Part A if they meet one of the below-listed criteria:

• Receiving federal disability benefits for 24 consecutive months
• Determined to have End-Stage Renal Disease (ESRD) and meet certain requirements

If you do not qualify for premium-free Part A, but you sign up and pay premiums for it, you must also have Medicare Part B (medical insurance). In these cases, recipients pay a single monthly premium for both services.

If you choose not to buy Part A, you can still buy Part B.

What are the requirements for Medicare Part A eligibility?

Beneficiaries become eligible for Medicare Part A when they qualify according to any of the below-described factors:

• Turning age 65 or older and a US citizen or legal permanent resident for at least five years in a row
• Receiving federal retirement benefits
• Be physically challenged and receiving disability benefits for 24 months
• Diagnosed with end-stage renal disease (ESRD)
• Be diagnosed with amyotrophic lateral sclerosis (ALS)

How does initial enrollment work for Part A?

Importantly, the law provides an initial enrollment period of seven months.

This time spans three full months prior to turning 65, the full month your 65th birthday lies in, and three full months after turning 65.

Those who fail to enroll in the seven-month period around their 65th birthday may have to wait until a general or special enrollment period. Along with this, some may have to pay a late enrollment penalty.

What is the General Enrollment Period?

Outside of the seven-month Initial Enrollment Period (IEP) surrounding the applicant’s 65th birthday month, there is a General Enrollment Period (GEP) in which any eligible person may apply.

The general enrollment period for Medicare runs from January 1 through March 31 of each calendar year.

If the GEP lies outside your seven month IEP, then coverage for Part A and/or B does not begin until July of that year.

What is a Special Enrollment Period?

There are Special Enrollment Periods (SEP) for Medicare that is based on life circumstances.

Especially when it comes to retirement, an SEP can allow Medicare Part A and/or B to replace employer-offered coverage when it ends.

The SEP also helps those with healthcare through their spouse’s employer or union.

Additionally, there are other special enrollment periods related to life changes, natural disasters, and other situations.

Immediate Enrollment

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 related to loss of employer coverage begins in the month after the loss of coverage.

The SEP starts the month after the previous coverage ends; it runs for eight consecutive months.

In some cases, 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.

When qualified for an SEP those who purchase a Medicare A and pay its premium do not have to pay the late enrollment penalty .

In short, those that qualify for an SEP get coverage the first month after enrollment. They usually get a Medicare card within thirty days of enrollment.

How will my other insurance coverage work with Medicare?

Medicare A works with Medicare Part B to combine hospital insurance with medical insurance.

In addition, insurance coverage from private providers can help pay the difference of cost when Medicare pays partly.

Certain types of these private plans offer necessary coverage for prescriptions.

Particular policies can even upgrade certain options for hospitals and facilities such as private rooms and extras.

The Affordable Care Act made changes across health insurance, which expanded benefits under Medicare Part A, adding further no-charge testing and examinations to detect early stages of serious diseases.

Undoubtedly, 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 need to be paid by the secondary coverage.

How does Part A decide what to cover?

The precise rules, interpretations, and exceptions come from three sources of authority.

First, Congress, which creates national policies.

Second, the Centers for Medicare and Medicaid Services (CMS), which issues program rules.

Third, there are local rules developed by claims processes as well as reviews of program actions.

In summary:

1. Congress creates laws which standardize national policy on hospital insurance.
2. The Centers for Medicare and Medicaid Services enforce national coverage decisions after deciding on a national scale whether to cover a service, supply, or item of equipment.
3. Local coverage decisions for medical necessity made by companies in each state that process claims for Medicare. These companies decide on a local area basis whether something is necessary and should be covered.

Together, 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 review systems of local experiences contribute to positive trends and advances.