Medicare is a federally backed healthcare provider. Having Medicare coverage can help you significantly in covering medical expenses. Continue reading to find out more.
What is Medicare Part A? What does it cover? These are just some of the questions you must be asking yourself. Medicare Part A assists in paying for the expenses of inpatient care in the hospital and also helps cover short-term skilled nursing facilities — such as a semiprivate room, bed, meals, and nursing care. It also covers specific home health services and hospice care. Moreover, it will cost you nothing if you meet the conditions for coverage.
When it comes to Part A benefits, you do not have to pay any premiums, given that you or your spouse has earned 40 credits via paying Medicare payroll taxes at work (which is the same as about 10 years of work). If they are not eligible for premium-free benefits, you can still get Part A coverage by paying monthly premiums for it.
Part A benefits are completely covered in both the original Medicare program and in Medicare Advantage plans. However, you pay for hospital care (deductibles and copays) in various ways based on what system you’re enrolled in, or, if you are in the Medicare Advantage program, which plans you are in.
What Is Medicare Part A?
Medicare Part A is one of four segments of the federal government’s health insurance program for older adults and other qualified individuals. Medicare Part A helps to pay for expenses related to inpatient hospital stays, skilled nursing facility care, inpatient care in a skilled nursing facility, hospice care, and home health care. It covers costs, for example, semi-private rooms at skilled nursing facilities, inpatient care, supplies, and medications during a hospital stay,as well as physical and occupational therapy in your home on the off chance that you are homebound. Doctor’s services, medication, and grief-and-loss counseling for terminally sick patients are also covered.
Understanding Medicare Part A
Medicare Part A, or Medicare hospital coverage, pays for care at a hospital, skilled nursing facility, or nursing home, and also for home health services. People who have enrolled and have paid Medicare taxes during their working years or individuals whose companions paid these taxes, do not pay premiums for Medicare Part A once they are 65 years old. This means that you have already paid your premiums through the 1.45% Medicare payroll tax that you and your employer each paid on all of your wages.
On the off chance that you did not pay this tax during your working years, the premiums are several hundred dollars for each month. This can be as high as $471 in 2021. Younger individuals who get long-term Social Security disability benefits also qualify for premium-free Part A. In any case, even when Medicare Part A is premium-free, a great many people will still have out-of-pocket costs for copayments and coinsurance.
Individuals protected under Medicare actually have to pay deductibles, as well. For 2021, deductibles for inpatient hospital stays are $1,484. This payment covers the initial 60 days of a patient’s stay in the hospital. Co-pays kick in after the 61st day. Patients are liable for a $371 copay for the 61st to 90th day in the hospital.
What does Medicare Part A cover?
Medicare Part A hospital care coverage
As a beneficiary of Medicare Part A, you will get coverage for hospital expenses that are important to your inpatient care, for instance, a semi-private room, meals, nursing services, medications that are part of your inpatient treatment, and many services and supplies from the hospital. This incorporates inpatient care that is received through:
- Acute care hospitals
- Critical access hospitals
- Inpatient rehabilitation facilities
- Long-term care hospitals
- Mental health care
- Participation in a qualifying clinical research study
Keep in mind that Medicare Part A hospital insurance does not provide coverage for the costs for a private room (unless it is medically necessary), private-duty nursing, personal care items like shampoo or razors, or other extraneous costs like telephone and television. Moreover, Medicare Part A also does not provide coverage for the cost of blood. If the hospital gets it through a blood bank at no charge, then you do not need to pay anything. However, if the hospital needs to buy blood for you, then you only have to pay for the first three units that you receive for every calendar year unless someone donates their blood to you.
Medicare Part A home health coverage
The advantages that Medicare Part A provides for home health care services are only covered when it is thought to be medically necessary and is ordered by your doctor. Some home health care services that are covered by Medicare Part A are as follows:
- Durable medical equipment, when ordered by your doctor
- Medical social services
- Occupational therapy
- Part-time or intermittent home health aide services
- Part-time or intermittent skilled nursing care
- Physical therapy
- Speech-language pathology services
Keep in mind that if your doctor orders durable medical equipment as part of your care and the equipment meets eligibility prerequisites, this expense is covered separately under Medicare Part B. In case you are qualified for coverage, Medicare typically covers 80% of the Medicare-approved amount for durable medical equipment.
Medicare Part A does not cover 24-hour home care, meals, or homemaker services if they are unrelated to your treatment. It also does not cover personal care services, like assistance with bathing and dressing, if this is the only care that you need.
Medicare Part A covers the whole expense for covered home health care services. As mentioned before, in the event that you need durable medical equipment, and it is arranged by your doctor it would be covered under Medicare Part B and you are liable for 20% of the Medicare-approved amount. Home health care should be given by a Medicare-certified home health agency, and a doctor should ensure that you are home-bound. According to Medicare, you are “homebound” if:
- Under normal circumstances, you cannot leave your home, and if doing so would require substantial effort.
- It is not medically advised for you to leave your home without the help of another person, transportation, or special equipment.
Medicare Part A nursing home coverage
Skilled nursing facility (SNF) stays are covered under Medicare Part A after a qualifying hospital inpatient stays for a related sickness or injury. To qualify for SNF care, the hospital stay should be at least three days, starting on the day you are formally admitted as an inpatient. The day you are discharged does not count towards this minimum three-day necessity. Time spent under observation as an outpatient is also not included in your qualifying stay. Skilled nursing care should be given at a Medicare-certified facility. Medicare-covered skilled nursing care incorporates, however, is not restricted to:
- Ambulance transportation to the nearest provider if needed services are not provided at the SNF
- Dietary counseling
- Medical social services
- Medical supplies and equipment used in SNF
- Medications received while in SNF care
- Rehabilitation services, if they are medically necessary to treat your illness
- Semi-private room
- Skilled nursing services
Your doctor must verify that you need daily skilled care which you cannot get at home, for example, intravenous drugs or physical therapy. Medicare Part A does not cover long-term care (or personal care, if that is the only care you need).
Medicare Part A hospice coverage
If your doctor has guaranteed that you have a terminal ailment with an estimated six months or less to live, you may be qualified for hospice care coverage. In hospice care, the attention is on palliative care, not on curing your disease. The goal is to alleviate pain and make the patient as comfortable as possible. To qualify for Medicare-covered hospice care, you should meet all the accompanying conditions:
- Your doctor or health provider should verify that you are terminally ill and have six months or less to live.
- You must agree to give up curative treatments for your terminal illness. However, Medicare will still cover palliative (comfort-focused) treatment for your terminal illness, as well as related symptoms or conditions.
- You must receive hospice care from a Medicare-approved hospice facility.
- You should be enrolled in Medicare Part A.
The patient usually gets Medicare Part A hospice care in their home. It may include, but is not restricted to:
- Dietary counseling
- Doctor services
- Durable medical equipment
- Homemaker services
- Hospice aide services
- Medical supplies
- Nursing care
- Pain relief medications
- Physical and occupational therapy
- Short-term inpatient care (if necessary for managing pain or symptoms)
- Short-term respite care
- Social services
In the event that a patient is under hospice care, Medicare Part A may also take care of certain costs that Medicare normally does exclude, for example, spiritual and grief counseling. Medicare Part A possibly pays for room and board in a hospital if the hospice medical team orders short-term inpatient stays for pain or other symptom management. Although you should surrender any curative treatments for your terminal sickness to get Medicare coverage, you have the option to stop hospice care at any time. Make sure that you talk to your doctor, if you are thinking of returning to curative treatments.
Medicare Part A Eligibility
Generally speaking, you are qualified for Medicare Part A if you meet the citizenship and residency requirements and you:
- Are aged 65 or older.
- Get disability benefits because you have amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s disease.
- Get disability benefits from Social Security or the Railroad Retirement Board for at least 25 months.
- Have end-stage renal disease (ESRD) and meet certain requirements.
How to Sign Up for Medicare Part A
Once they are eligible, a lot of people are automatically enrolled. On the other hand, some have to sign up for it. In general, it relies upon whether you are receiving Social Security benefits. You may, for instance, be automatically enrolled in Medicare Part A and Medicare Part B if you:
- Have amyotrophic lateral sclerosis (ALS), also called Lou Gehrig’s disease. You will automatically get Medicare Parts A and B when your disability benefits begin.
- Have received benefits from Social Security or the Railroad Retirement Board for at least four months before you turn 65.
- Have received Social Security benefits for at least 2 years.
- If you have end-stage renal disease (ESRD), you are qualified for Medicare and can enroll in Parts A and B or in a Medicare Advantage Plan. If you opt for Original Medicare (Parts A and B), you will need both parts to get the full benefits available with Medicare to cover specific dialysis and kidney transplant services. If you are interested in a Medicare Advantage Plan, make sure to check that the healthcare providers you currently see or want to see in the future, are in the plan’s network.
If you are not automatically enrolled in Medicare and you will be qualified when you turn 65, you should sign up through Social Security during your initial enrollment period. This is a seven-month period that:
- Ends three months after the month you turn 65.
- Enrollment can be done online, by phone, or at a Social Security office.
- Includes the month you turn 65.
- Starts three months before the month you turn 65.
Is Medicare Part A free?
Premium-free Part A
You usually do not pay a monthly premium for Medicare Part A (Hospital Insurance) coverage in the event that you or your companion paid Medicare taxes for a certain amount of time while working. This is now and then called “premium-free Part A.” Most individuals can be eligible for premium-free Part A. You can get premium-free Part A at 65 if:
- You already get retirement benefits from Social Security or the Railroad Retirement Board.
- You are eligible to get Social Security or Railroad benefits but haven’t filed for them yet.
- You or your spouse had Medicare-covered government employment.
If you are under 65, you can get premium-free Part A if:
- You got Social Security or Railroad Retirement Board disability benefits for 24 months.
- You have End-Stage Renal Disease (Esrd) and meet specific requirements.
Part A premiums
If you are not eligible for premium-free Part A, you can purchase it. People who purchase Part A will pay a premium of either $259 or $471 each month in 2021 based on how long they or their husband/wife worked and paid Medicare taxes. If you decide not to purchase Part A, you can still buy Part B. In most cases, if you decide to purchase Part A, you must also:
- Contact Social Security for more information about the Part A premium.
- Find out what Part A covers.
- Find out what you pay for Part A-covered services.
- Have Medicare Part B (Medical Insurance)
- Learn how and when you can sign up for Part A.
- Pay monthly premiums for both Part A and Part B
What are the other three types of Medicare?
Medicare is certainly quite difficult to understand and can be confusing to sort through. To make it simpler, the program has been divided into four fundamental parts that include coverage for everything; ranging from hospital care to doctor visits to prescription drugs. We have already talked about ‘Part A — Hospital coverage’ in detail, so let us take a look at the other three.
Part B — Doctor and outpatient services
This part of Medicare covers visits to the doctor, lab tests, diagnostic screenings, medical equipment, ambulance transportation and other outpatient services. Unlike Part A, Part B includes more expenses, and you may want to concede signing up for it in the event that you are still working and have insurance through your work or are covered by your spouse’s health plan. However, if you do not have other insurance and do not sign up for Part B when you initially take on Medicare, you will probably have to pay a higher monthly premium for as long as you are in the program.
The federal government sets the Part B monthly premium, which is $148.50 for 2021. It could be higher if your income is more than $88,000. You will also be subject to an annual deductible, set at $203 for 2021. And you will have to pay 20 percent of the bills for visits to the doctor and other outpatient services. In the event that you are gathering Social Security, the monthly premium will be deducted from your monthly advantage.
Part C — Medicare Advantage
Medicare Advantage is the private health insurance alternative to the federally run original Medicare. Consider Advantage as a sort of one-stop shopping decision that joins various parts of Medicare into one plan. In the event that you settle on a Medicare Advantage — or MA — plan, you will still have to enroll in parts A and B and pay the Part B premium. In addition, you should pick a Medicare Advantage plan and sign up with a private insurance provider.
The federal government requires these plans to cover all that original Medicare covers, and a few plans pay for services that original Medicare does not, including dental and vision care. In addition, as of late the Centers for Medicare and Medicaid Services, which sets the principles for Medicare, has allowed Medicare Advantage plans to cover such extras as wheelchair ramps and shower holds for your home, meal delivery and transportation to and from your doctors’ office. Most Medicare Advantage plans also include prescription drug coverage. Not all of these plans cover the same extra advantages, so make sure to read the plan descriptions carefully.
Medicare Advantage plans generally are either health maintenance organizations (HMOs) or preferred provider organizations (PPOs). In HMOs you typically pick a primary care doctor who will then direct your care and usually would give you a referral to see a specialist. PPOs have organizations of specialists that you can see and facilities you can utilize, frequently without the need of a referral. On the off chance that you visit a provider who is not in the plan’s network, you probably will pay more.
Part D — Prescription drugs
This is the part of Medicare that pays for a portion of your prescription medications. You purchase a Part D plan through a private insurer. Each generally has premiums and other out-of-pocket expenses, either flat copays for each medication or a percentage of the prescription costs. It also may have an annual deductible. On the off chance that your total medication costs — the amount you and your Part D insurance plan have paid — reach $4,130 in 2021, you will be responsible for 25 percent of the cost of the remainder of the prescription medications you purchase during the year.
On the off chance that your medication costs keep on mounting, you may reach the point of qualifying for catastrophic coverage. For 2021, whenever you have paid $6,550 for medications — exactly what you paid, excluding what your Part D insurance plan paid — you will be liable to pay for 5 percent of the expense for each of your medications.
Make certain to check medicare.gov whether the plan you are thinking about has the medications you take on its covered list, called a formulary. Those lists change from one year to another, so reevaluate your plan each year at open enrollment time. The following open enrollment will be from Oct. 15 to Dec. 7, 2021, and any changes you make will take effect in January 2022.
What is the difference between Medicare Part A and B?
Many individuals do not pay a monthly premium for Medicare Part A. For example, on the off chance that you worked at least ten years (40 quarters) while paying taxes, you do not pay a premium for Part A. In the event that you worked for less than 30 quarters, you generally pay $471 each month in 2021. In the event that you worked more than 30, however less than 40 quarters, your premium is $259 each month in 2021. Your Part B premium may be the “standard” amount, or $148.50 in 2021. On the off chance that your income is above a certain amount (based on your income tax returns from two years ago), you may pay a higher Part B premium.
Special Considerations for Medicare Part A
Although Medicare Part A covers many hospital-related services, it does not cover everything. Suppliers should ask patients to sign a notice prior to getting treatment when a service may not be covered. This strategy allows the patient to pick whether to accept the service and pay for it using cash on hand or to decline the help.
To be proactive about keeping your medical bills down, it is a smart idea to find out before utilizing a Part A service if Medicare will cover all, part, or none of the expense. In the event that Medicare will not cover enough of the cost, find out why that is the case. There may be an alternative that is covered that would in any case help you, or you can document an appeal to attempt to get the coverage choice changed in your favor.
The three reasons why Medicare Part A might not cover something are:
- General federal and state laws
- Local Medicare claims processors’ assessment of whether a service is medically necessary
- Specific federal laws about what Medicare covers
One example of an assistance Medicare does not usually cover is custodial care in a skilled nursing facility — assistance with basic activities of daily living, for example, getting dressed, bathing, and eating — if it is the only care you need. You should have more genuine medical requirements for Medicare to cover your stay at a nursing home.
Generally, the various parts of Medicare assist with covering certain services. Most beneficiaries decide to get their Parts A and B benefits through Original Medicare, the traditional fee-for-service program which is directly offered through the federal government. It is often called Traditional Medicare or Fee-for-Service (FFS) Medicare. Under Original Medicare, the government pays directly for the health care services you get. You can see any doctor and hospital that takes Medicare (and most do) anywhere in the country.
However, if you pick something else, you will have Original Medicare. Instead of Original Medicare, you can choose to get your Medicare benefits through a Medicare Advantage Plan, also called Part C or Medicare private health plan. Keep in mind, you still have Medicare if you enroll in a Medicare Advantage Plan. This means that you should in any case pay your monthly Part B premium (and your Part A premium in the event that you have one). Each Medicare Advantage Plan should give all Part A and Part B services covered by Original Medicare, however they can do as such with various principles, expenses, and limitations that can affect how and when you get care.
Understand your Medicare coverage decisions and to pick your coverage carefully. How you decide to get your advantages and who you get them from can affect your out-of-pocket expenses and where you can get your care. For instance, in Original Medicare, you are covered to go to nearly all doctors and hospitals in the country. Then again, Medicare Advantage Plans typically have network limitations, which means that you will probably be more restricted in your selection of doctors and hospitals. In any case, Medicare Advantage Plans can also give additional advantages that Original Medicare does not cover, like routine vision or dental care.