Medicare Part A deals with inpatient care, which includes care in a skilled nursing facility, a hospital, and in some cases, at home. Part A is part of Original Medicare which has two parts: Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).
If you’re 65 and receiving retirement benefits from the Railroad Retirement Board or Social Security. Then you should be automatically eligible for Medicare Part A. If you are not 65 yet, you still may qualify for Medicare Part A. This is if you have a disability, ALS (amyotrophic lateral sclerosis), or ESRD (end-stage renal disease). You also must be a citizen of the U.S. or a legal permanent resident for at least five consecutive years.
Below is what Medicare Part A coverage consists of:
- Hospice care
- Skilled nursing facility care, if custodial care isn’t the only care mandatory.
- Limited home health services
- Hospital care (inpatient)
*Please be aware that you must meet certain conditions for the above benefits to apply.
What You Get In Medicare Part A hospital care coverage
Coverage that you will get as a beneficiary of Medicare Part A include:
- Meals
- A semi-private room
- Medications that are part of our inpatient treatment
- Any other services and supplies from the hospital
This will include the impatient care you get from:
- Mental health care
- Long-term care hospitals
- Participation in a qualifying clinical research study
- Inpatient rehabilitation facilities
- Critical access hospitals
- Acute care hospitals
Here is what Medicare A hospital insurance does not cover the costs for:
- Personal care items like razors or shampoo
- Private-duty nursing
- A private room (unless medically necessary)
- Other medically unrelated charges like television and phone charges.
Also note that Medicare Part A will not cover blood cost. If you need blood donated to you, then you only have to pay for the first three units of blood that you get each calendar year. This does not apply if you or someone else is the one donating blood.
What are the home health care benefits for Medicare Part A
The coverage for your Medicare Part A plan may include home health care services. This is only possible if your doctor orders it to be medically necessary.
Services for home health care compromise of:
- Intermittent or part-time home health aide services
- Medical social services
- Occupational therapy
- Durable medical equipment (if your doctor orders it)
- Speech-language pathology services
- Physical therapy
- Part-time or intermittent skilled nursing care
*Please note that Medicare Part B may cover the cost of durable medical equipment. This is if the doctor orders the equipment and it’s part of your care and meets eligibility requirements. Generally, Medicare will cover 80% of the cost for the durable medical equipment if it is Medicare-approved.
If services like 24-hour home care, meals, or homemaker services are independent from your treatment. Then Medicare Part A will not cover them. Also, if personal care services like bathing and dressing is the only care you need, then Part A will not cover it.
Medicare Part A will pay for the cost for home health services. Unless it is under the Medicare Part B requirements, then you will pay 20% of the Medicare-approved amount as stated above. A Medicare-certified home health agency must provide the home health care. And a doctor has to verify that you are homebound. To be considered “homebound,” two things must be true:
- You cannot leave your home under normal circumstances.
- If you need to leave your home, you must do so with the help of another person, special equipment, or transportation.
Nursing Home Coverage for Medicare Part A
Medicare part A covers skilled nursing facility (SNF) stays. SNF happens after a qualifying hospital inpatient stay for a correlated injury or illness. In order to qualify for SNF care, your hospital stay must be at least 3 days, starting on the day you are officially taken as an inpatient. Being under observation as an outpatient does not count toward your 3-day qualification. The qualification also does not count the day you are discharged.
A Medicare-certified facility must provide skilled nursing care. Below are the services that a Medicare-covered skilled nursing care incorporates, but not limited to:
- Dietary counseling.
- If required services that are not provided at the SNF, then you will get ambulance transportation to the nearest provider.
- Medical equipment and supplies used in SNF.
- Medications that you get while in SNF care.
- Rehabilitation services that are medically needed to treat your sickness or injury.
- Medical social services.
- Skilled nursing services.
- Meals
- Semi-private room
If you cannot get skilled care that you need but at home, like intravenous drugs or physical therapy. Then your doctor must approve that you need such care. Long term care (or personal care, if it’s the lone care you need) is not covered by Medicare Part A.
Are you eligible for Medicare Part A Hospice care coverage?
How do you know if you are eligible for Hospice care coverage? You may be eligible for hospice care coverage if your doctor has certified that you have a terminal illness (Six months or less to live). During hospice care, the focal point is not to cure your disease but on alleviating care. So, the goal is to make the patient as comfortable as possible and calm the pain.
You must meet every single condition below to qualify for Medicare-covered hospice care:
- You have to get hospice care from a Medicare-approved hospice facility.
- If you have any curative treatments for your terminal illness, you must agree to give that up. However, Medicare will still cover any alleviative (comfort-focused) treatment for your terminal illness.
- Your doctor has to verify that you have six months or less to live with a terminal illness.
- You are already enrolled in Medicare Part A.
Generally, you will get Medicare Part A hospice care in your home. Below are the services you will get, but not limited to:
- Short-term respite care
- Short-term inpatient care (for managing symptoms or pain, if necessary)
- Dietary counseling
- Occupational and physical counseling
- Hospice aide services
- Homemaker services
- Medical supplies
- Durable medical equipment
- Social services
- Pain relief medications
- Nursing care
- Doctor services
In a hospital, if the hospice medical team dictates short-term inpatient stays for symptom or pain management. Then Medicare Part A will only pay for the room and board fee. However, Medicare Part A may also cover some costs that Medicare does not usually include like spiritual and grief counseling. This applies if a patient is under hospice care.
You will always have the right to stop hospice care at any time. Talk to your doctor if you would like to go back to curative treatments and stop hospice care.
The Eligibility Requirements for Medicare Part A
Typically, below is a list of qualifications for Medicare Part A. Just one qualification will be enough for eligibility:
- You have ALS (amyotrophic lateral sclerosis, also called Lou Gehrig’s disease).
- You have end-stage renal disease (ESRD).
- You are already getting retirement benefits.
- You are getting disability benefits and currently disabled.
- You are age 65 or older and a United States citizen or permanent legal resident of at least 5 consecutive years in a row.
Usually, if you have worked at least 10 years (or 40 quarters) and paid Medicare taxes, you will not pay a premium for Part A Medicare. You can still enroll in Part A if you are not eligible for premium-free Medicare Part A, you will just have to pay a premium. If you postpone your enrollment after your Initial Enrollment Period for Medicare Part A, then you may have to pay a late enrollment penalty once you sign up.
The Initial Enrollment Period For Medicare Part A
If you are getting Railroad Retirement board or Social Security benefits and are already 65. Then, normally your enrollment in Medicare Part A will be automatic. Medicare Part A benefits will start on the 1st day of the month when you turn 65. Note that your Medicare Part B coverage will start at the same time if you enrolled in Medicare Part B. You will get a red, white, and blue Medicare card in the mail 3 months before your 65th birthday.
If you do not qualify for the required disability benefits (Social Security and Railroad Retirement Board). Then you have to enroll manually in Medicare Part A during your IEP (Initial Enrollment Period). Here’s how you can enroll:
- Through the Social Security website
- Calling 1–800–772–1213 (TTY users 1–800–0778), Monday through Friday, from 7AM to 7PM.
- Visiting a local Social Security office.
How long is the IEP? The Initial Enrollment Period is a 7-month time frame that starts 3 months before the month you turn 65, the month of your 65th birthday, and ends 3 months after. Whichever month you enroll during your IEP will determine when your coverage begins. Avoid procrastinating until the last minute to enroll. You must want until the next general enrollment period (GEP) if you do not enroll during your seven-month IEP. The GEP will be January 1 to March 31.
If you have been receiving Social Security disability benefits for 24 months and you are currently disabled. Then you will have automatic enrollment in Medicare Part A hospital insurance (and Medicare Part B medical insurance). Your Medicare card will arrive in the mail on the 22nd month. And your coverage will start 3 months after, on the 25th month.
If you have ALS (or Lou Gehrig’s disease), then whenever your Social Security disability benefits start, your Original Medicare (Part A and Part B), will also start. One month after you sign up for Social Security disability benefits, your Medicare Card should arrive.
If you have ESRD (end-stage renal disease) and you are in need of dialysis. Then, generally, the 1st day of the 4th month of your dialysis treatment is when your Medicare effective date will begin. Note that you will not be automatically enrolled if you’re younger than 65, so you need to apply for your Medicare benefits.
General Enrollment Period for Medicare Part A
You can enroll in Medicare Part A during the next General Enrollment Period (GEP) if you missed your Initial Enrollment Period (IEP). Enrollment from the GEP happens every year from January 1 to March 31. Your coverage will begin July 1 of the year you enrolled and your Medicare card will arrive 3 months before your coverage starts.
You may have to pay a late-enrollment penalty if you are not eligible for premium-free Medicare Part A and you did not enroll when you were first eligible.
Special Enrollment Period for Medicare Part A
Do you qualify for an immediate enrollment of Medicare Part A or a Special Enrollment Period? If you were a volunteer serving in a foreign country or if you (or your spouse) lose your union-or employer-sponsored group hospital insurance. Then you may enroll in Medicare Part A during a Special Enrollment Period. This is an 8-month time window that starts after your group coverage or employment ends. However, follow the standard rules for initial enrollment in Part A if your employment ends during your IEP. If you qualify for a Special Enrollment Period, then you normally do not have to pay the late-enrollment penalty for Part A, if you pay a premium. Your Medicare card should appear in your mail within 30 days of your enrollment. And your Medicare Part A coverage will start the first of the month after you enroll.