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Medicare Part A covers hospital or skilled nursing facility stays.
In short, Medicare Part A beneficiaries receive insurance coverage for inpatient hospital expenses that doctors determine medically necessary.
For example, the rules cover a semi-private room, nutritionally balanced meals, skilled nurse’s care, and medicines that comprise a necessary part of the inpatient care.
Namely, inpatient care under Medicare Part A covers mental health care providers, rehabilitation facilities, skilled nursing facilities and acute care hospitals. Part A also covers certain clinical studies for chosen participants.
Last but not least, the hospital must accept Medicare, and in some cases a committee will review and approve your stay while in the hospital.
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.
In five broad areas, Medicare Part A covers 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 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.
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:
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.
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:
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.
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 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:
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.
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.
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:
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.
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:
Persons under age 65 get Premium-free Part A if they meet one of the below-listed criteria:
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.
Beneficiaries become eligible for Medicare Part A when they qualify according to any of the below-described factors:
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.
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.
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.
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.
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.
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:
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.
