Once you apply for Medicare, you will receive Part A Medicare. Although most do not pay a monthly premium, due to the collection during past years of employment, some may have to. To start here is a quick table showing the premiums, deductibles and co-insurance of Medicare Plan A, followed by the plan review of coverage.
|Part A premium||Most people don't pay a monthly premium for Part A (sometimes called "premium-free Part A"). If you buy Part A, you'll pay up to $422 each month. If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $422. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $232.|
|Part A hospital inpatient deductible and coinsurance|| You pay:
In general medicare part A covers:
- Hospital Care
- Skilled Nursing facility care
- Nursing home care (as long as custodial care isnt the only care you need)
- Home health services.
Inpatient Hospital Care covers:
- Semi-private rooms
- General nursing
- Drugs as part of your inpatient treatment
- Other hospital services and supplies
This includes the care you get in these facilities:
- Acute care hospitals
- Critical access hospitals
- Inpatient rehabilitation facilities
- Long-term care hospitals
It also includes these:
- Inpatient care as part of a qualifying clinical research study
- Inpatient mental health care given in a psychiatric hospital or other hospital
What's not covered
- Private-duty nursing
- Private room (unless medically necessary)
- Television and phone in your room (if there's a separate charge for these items)
- Personal care items, like razors or slipper socks
All people with Part A are covered when all of these are true:
- A doctor makes an official order which says you need 2 or more midnights of medically necessary inpatient hospital care to treat your illness or injury, and the hospital formally admits you.
- You need the kind of care that can be given only in a hospital.
- The hospital accepts Medicare.
- The Utilization Review Committee of the hospital approves your stay while you're in a hospital.
Skilled nursing facility care:
Medicare-covered services include, but aren't limited to:
- Semi-private room (a room you share with other patients)
- Skilled nursing care
- Physical and occupational therapy (if they're needed to meet your health goal)
- Speech-language pathology services (if they're needed to meet your health goal)
- Medical social services
- Medical supplies and equipment used in the facility
- Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren’t available at the SNF
- Dietary counseling
If you're in a SNF, there may be situations where you need to be readmitted to the hospital. If this happens, there's no guarantee that a bed will be available for you at the same SNF if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there's a cost to hold the bed for you.
People with Medicare are covered if they meet all of these conditions:
- You have Part A and have days left in your benefit period.
- You have a qualifying hospital stay.
- Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. If you're in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they're offered.
- You get these skilled services in a SNF that's certified by Medicare.
- You need these skilled services for a medical condition that was either:
Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you're getting observation services in the hospital, you're considered an outpatient—you can't count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay. Find out if you're an inpatient or an outpatient.
Remember, any days you spend in a hospital as an outpatient (before you’re formally admitted as an inpatient based on the doctor’s order) aren’t counted as inpatient days. An inpatient stay begins on the day you’re formally admitted to a hospital with a doctor’s order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day.
- If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.
- If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.
Long term care hospitals:
How often is it covered?
- They may have more than one serious condition.
- They may improve with time and care, and return home.
Your costs in Original Medicare
Generally, you won't pay more for care in a long-term care hospital than in an acute care hospital. Under Medicare, you're only responsible for one deductible for any benefit period. This applies whether you're in an acute care hospital or a long-term care hospital (LTCH).
You don't have to pay a second deductible for your care in a LTCH if:
- You're transferred to a LTCH directly from an acute care hospital
- You're admitted to a LTCH within 60 days of being discharged from an inpatient hospital stay
If you're admitted to the LTCH more than 60 days after any previous hospital stay:
- A new benefit period begins.
- You'll have to pay a deductible and coinsurance because you're in a new benefit period. These charges are the same as if you were being admitted to an acute care hospital.
If you qualify for hospice care, you and your family will work with the hospice team. Together you'll set up a plan of care that meets your needs.
Home healthcare services
How often is it covered?
- Part-time or intermittent skilled nursing care
- Part-time or intermittent home health aide care
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social services
Usually, a home health care agency coordinates the services your doctor orders for you.
Medicare doesn't pay for:
- 24-hour-a-day care at home
- Meals delivered to your home
- Custodial or personal care (help bathing, dressing, and using the bathroom) when this is the only care you need
- Homemaker services
All people with Part A and/or Part B who meet all of these conditions are covered:
- You must be under the care of a doctor, and you must be getting services under a plan of care created and reviewed regularly by a doctor.
- You must need, and a doctor must certify that you need, one or more of these:
- Intermittent skilled nursing care (other than drawing blood)
- Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either: 1) your condition must be expected to improve in a reasonable and generally predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition.The home health agency caring for you is approved by Medicare (Medicare certified).
- You must be homebound, and a doctor must certify that you're homebound.
You're not eligible for the home health benefit if you need more than part-time or "intermittent" skilled nursing care.
You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.
Your costs in Original Medicare
Before you start getting your home health care, the home health agency should tell you how much Medicare will pay. The agency should also tell you if any items or services they give you aren't covered by Medicare, and how much you'll have to pay for them. This should be explained by both talking with you and in writing. The home health agency should give you a notice called the "Advance Beneficiary Notice of Noncoverage" (ABN)before giving you services and supplies that Medicare doesn't cover.
This information was taken from Medicare.gov, the official site of Medicare.