Medicare Part A: The Whole Story

It’s intimidating, choosing the right Medicare coverage. So, let’s start with the basics — what’s known as Original Medicare — which consists of Part A and Part B and is managed by the federal government. This article will focus on Part A, taking you through everything you need to know, including coverage, eligibility, enrollment, and costs. The two parts of Medicare provide hospital insurance (Part A), and medical insurance (Part B).

Broadly, Medicare Part A coverage offers:

It’s important to know that some of these benefits will apply only after certain conditions are met, which we’ll explain later in detail.

What is My Hospital Coverage Under Part A?

With Medicare Part A, you don’t have to worry about the main costs of your hospital stay. This means a semi-private room, meals, nursing services, medications, and other needed services and supplies. Part A usually covers around 80% of the “Medicare-approved amount,” or the amount the program deems reasonable for where you live and the care you received.

The range of health care facilities include:

Acute-care hospitals
Critical-access hospitals
Inpatient rehabilitation facilities
Mental health care
Long-term care
Participation in a qualifying clinical research study

Part A does not cover private room costs (except when medically necessary), the duties of a private nurse, shampoo, razors and other personal care items, and extra charges such as television or telephone.

Getting into deeper detail, you should know that if the facility does not get blood free from a blood bank, you will have to cover the costs, but just for the first three units per calendar year as needed. For longer hospital stays, you’ll be responsible for a larger share of the costs. This is when it makes sense to have supplemental insurance.

What Kind of Nursing Care Can I Expect With Part A?

If you are an inpatient whose treatment qualifies for a skilled nursing facility (SNF) stay, you must be under hospital care for a minimum of three days from the initial admission date. Your discharge day does not figure in the three-day minimum, as well as time under observation. Skilled nursing care is only covered at a Medicare-certified facility.

The range of health care facilities include:

Semi-private room
Meals
Rehabilitation services
Social services
Medications received in SNF care
Medical equipment and supplies used in SNF
Dietary counseling
Ambulance transportation to closest facility if necessary services are not available at the SNF

If you need daily help with physical therapy or intravenous medications from a skilled nurse, you’ll need certification from your doctor.

How Can Part A Help With Home Health Care?

When ordered by a doctor, you can get home care covered under your Part A plan. Coverage Includes:

Part-time skilled nursing care
Physical therapy
Occupational therapy
Social services
Speech-language pathology services
Part-time home health aide services

The good news is that Part A covers your whole cost for home health care that’s provided by a Medicare-certified home health agency once your doctor has qualified that you’re home-bound. It does not cover 24-hour home care, or meals and other homemaker services outside your treatment protocol.

And What About Hospice Care?

In the case where your doctor has certified that your illness is terminal, and you have six months or fewer to live, hospice care may be covered by Part A. Conditions to be met:

When hospice care is administered in the patient’s home, as it often is, services may include:

Doctor services
Nursing care
Homemaker services
Dietary counseling
Medications for pain
Social services
Durable medical equipment

Part A may offer benefits such as grief counseling and spiritual services when the patient is in hospice care. Should you elect to return to curative treatments under advisement from your physician, it’s necessary to stop hospice care.

Am I Eligible for Part A?

If you’re among the tens of millions of Americans who are already collecting Social Security or Railroad Retirement Board (RRB) benefits at age 65, you are automatically eligible for Medicare Part A and Part B starting the first day of the month you turn age 65. If your birthday happens to fall on the first day of the month, then you’ll be automatically enrolled in Medicare on the first day of the month before your birthday. You should get your Medicare card in the mail 3 months before your 65th birthday.

If you’re close to 65 and not getting Social Security or Railroad Retirement Board benefits, it’s critically important that you contact the Social Security office 3 months before your 65th birthday to sign up for Medicare.

The general eligibility requirements for Part A are:

You are a U.S. citizen 65 years or older or a legal immigrant who has lived in the U.S. for at least 5 years
You are under 65 and have received Social Security Disability benefits for 24 months
You have end-stage renal disease (ESRD)
You have amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease)

If you or your spouse worked and paid Medicare taxes for less than 10 years, whatever time you worked will be taken into consideration when Social Security determines your Medicare Part A premium. The longer you or your spouse worked and paid taxes, the less you owe. Visit this page for more information on your Medicare Part A premiums and other costs: https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles.

No matter how old you are, if your spouse has turned 65 and paid at least ten years of Medicare taxes, you are eligible for Medicare Part A, even if you haven’t worked enough to qualify on your own.

What’s Involved With Enrollment, Automatic and Manual?

This is a bit complicated, but read slowly. Once eligible for Medicare, there’s a 7-month Initial Enrollment Period (IEP) to sign up for Part A. The way it works is, once you’ve turned 65, your 7-month IEP begins 3 months prior to your 65th birthday, includes your birthday month, and ends 3 months after.

If you or your spouse didn’t qualify for automatic enrollment through Social Security or RRB benefits, you need to enroll during the IEP to get Medicare Part A.

Here are your 3 options:

Go to www.ssa.gov
Phone Social Security at 1-800-772-1213 (TTY users: 1-800-0778), Monday-Friday
Go to your local Social Security office. You can find it by visiting the Social Security Office Locator and entering your zip code

Part A is usually premium free, but if you didn’t sign up for it in the Initial Enrollment Period, your premium will go up 10% and you’ll have to pay the premium for twice the number of years you weren’t in Part A for not signing up.

In the case where you or your spouse had an employer- or union-sponsored group health plan, you can enroll in a Special Enrollment Period (SEP) during:

Signing up during the SEP means the late enrollment penalty is waived. Also, the SEP doesn’t apply to people eligible for Medicare based on end-stage renal disease.

There’s one final enrollment detail, an important one. If you weren’t automatically enrolled in Medicare and missed the IEP, you can still apply for Medicare Part A and/or Medicare Part B during the General Enrollment Period, which runs from January 1 to March 31 each year. If you enroll in Medicare during the General Enrollment Period, your coverage begins on July 1.

What is Part A Going to Cost Me?

There’s no premium for about 99 percent of Medicare beneficiaries who have at least 40 quarters of Medicare-covered employment. If you’re not eligible for premium-free Part A, you can still enroll and pay a premium. But if you miss the Initial Enrollment Period when you first become eligible, you may have to pay a late enrollment penalty once you sign up.

Here are the costs you need to be familiar with:

1. Medicare Part A deductible is $1,600 for each benefit period

2. Medicare Part A coinsurance:

$0 coinsurance for the first 60 days of each benefit period
$400 a day for the 61st to 90th days of each benefit period
$800 a day for days 91 and beyond per each lifetime reserve day of each benefit period (you get up to 60 lifetime reserve days)
After lifetime reserve days are used up, you pay all costs

Skilled nursing facility care:

What’s a “benefit period”? This is the time you are receiving hospital and skilled nursing facility (SNF) services. It begins the day you go into a hospital or skilled nursing facility and ends when you have been out for 60 consecutive days. If you go back in after one benefit period has ended, a new benefit period begins, and you must pay the inpatient hospital deductible again. There’s no limit to your number of benefit periods.

If you or your spouse worked and paid Medicare taxes for less than 10 years, the length of time that you worked will be taken into consideration when Social Security determines the amount you owe for your Medicare Part A premium. Your premium amount may be reduced the longer you or your spouse worked and paid taxes. Visit this page for more information on your Medicare Part A premiums and other costs: www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles.

Still confused? Call us!

We’re here at 833-245-0614 to answer any questions, and ready to help with any issues you might have with an insurer through the enrollment process.

FAQs

What amount does Part A pay of my hospital bill?

Part A usually covers around 80% of the Medicare-approved amount, or the amount the program deems reasonable for where you live and the care you received.

What basic things does Part A not cover?

Are prescription drugs covered by Part A?

Yes, medications prescribed during a hospital or skilled nursing facility stay are covered.

I didn't have a steady job for most of my life. Can I still get Medicare?

Yes, but only if you’re married and your spouse has turned 65 and paid at least ten years of Medicare taxes.

I have a disability. How does that affect my eligibility for Part A?

You can get Part A coverage if you are under 65 and have received Social Security Disability benefits for 24 months, have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease).

What are the best Medicare supplement plans?

Best overall Medicare supplement for new enrollees: Plan G.
Best overall Medicare supplement before 2020: Plan F.
Best low cost Medicare supplement: Plan K.
Best alternative to Plan G Medicare supplement: Plan N.