Part A: Hospital Insurance

Medicare is health insurance coverage provided by the US Federal Government. The program covers persons by age, 65 or older, medical condition, people on social security disability, and at high risk of organ failure. Medicare Part A is the particular portion of the federal Medicare program that covers hospital benefits.

Medicare Part A is the hospital insurance portion of Medicare. It is a set of services and benefits that come into action when a person covered by Part A must go to stay in a hospital or skilled nursing facility. Medicare Part A is part of the original Medicare program.

The Congress created Medicare, and the federal government operates the program. It provides benefits involving nursing services and hospital stays; in limited settings, it also provides for home care. The costs include premiums, deductibles, and doctor fees.

How does Medicare Part A coverage work?

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The general rule is that Medicare 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 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.

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.

For example, Medicare Part A does not cover the cost of blood. Some hospitals get donated blood without charge. Most hospitals do not charge when they receive donated blood.

Many patients choose to store their blood for later use. When hospitals purchase blood, they pass the costs to the insured. The rules allow hospitals to charge for the first three units per patient in each calendar year.

What does Medicare Part A help cover?

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In five broad areas, Medicare Part A coverage includes 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
  • Responsive end of life situations for patients, which can be mixed with services for comfort and dignity and which can be stopped whenever the patient wishes to return to normal treatment situations.
  • Nursing Home Care when more than custody care is needed

Medicare Part A – Nursing Home Coverage

hands-walking-stick-elderly-old-person-1600x1600Medicare 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 Medicare 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:

  • Treatment in a semi-private room
  • Serving nutritional meals that are balanced
  • Skilled nursing services such monitoring conditions and maintaining records
  • Rehabilitation services that are 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 not available at the skilled nursing facility
  • Dietary analysis and counseling

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. Medicare 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 – Home Health Care Benefits

 

AdobeStock_88855595-1600x1600Medicare 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.

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
  • Providing durable medical equipment if doctor ordered

Medicare 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.

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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:

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

Medicare Part A – Hospice Coverage

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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:

  • Successful enrollment in Medicare 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 and give up treatment for the terminal condition; Medicare agrees to cover comfort-focused treatment for the terminal illness, along with any related symptoms or conditions.
  • Only accept hospice care from a Medicare-approved facility.

In further understandings, the patient and Medicare agree to the following guidance.

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

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:

  • Doctor services – Medicare will provide medical services from doctors to alleviate pain and discomfort and to advise the patient.
  • Nursing care – Medicare will provide skilled nurses to provide services such as delivering medications and pain relieving procedures.
  • Pain relief medications – Medicare will provide pain relief medications and procedures as directed by the hospice medical care providers.
  • Comfort and support medical treatment – Medicare will provide social services, hospice aide services, dietary counseling, and homemaker services.
  • Equipment and therapy – Medicare will provide durable medical equipment, medical supplies, and physical and occupational therapy.
  • Short-term inpatient care – Medicare will provide short-term inpatient care if considered medically necessary for pain management or control of other symptoms.
  • Short-term respite care – Medicare will provide short-term respite care when medically advisable to manage pain and alleviate symptoms.

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. Medicare 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.

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.

How Much Does Part A Cost?

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Medicare 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.

  • Pre-qualified for federal retirement benefits
  • Eligible for but not receiving federal benefit
  • Applicant or spouse qualified government employee

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

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

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.

Eligibility for Medicare Part A

AdobeStock_10737604-1600x1600– What are the requirements for Medicare Part A eligibility?

In general, people age 65 or older are eligible for Medicare Part A if they have one or more of the below-described factors:

  • Must be age 65 or older and a US citizen, or legal permanent resident of at least five years in a row
  • Must be a person receiving retirement benefits
  • Must be a physically challenged person and receiving disability benefits
  • Must have severe kidney disease (ESRD)
  • Must have ALS (amyotrophic lateral sclerosis)

– How does initial enrollment work for Part A?

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.

– What is the General Enrollment Period?

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.

– What is the Special Enrollment Period?

There is a special enrollment period for Medicare 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.

– 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 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.

– How will my other insurance coverage work with Medicare?

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.

Part A coverage Policy and Details

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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.

  1. Federal and state laws which set national policy on hospital insurance.
  2. The federal government makes national coverage decisions made by Medicare; they decide on a national scale whether to cover a service, supply, or item of equipment.
  3. Medical necessity decisions come from local coverage decisions 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.

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.

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