What does Medicare Part A cover?
This article is part of an ongoing educational series on Medicare presented by the Good Samaritan Society.
Medicare Part A is the hospital insurance component of Medicare. Part A generally covers short-term inpatient care at hospitals and skilled nursing centers, as well as some home care and hospice services. There may be a deductible or co-pay for some care, services and equipment.
Your doctor or health care provider is your first resource to ask about what services and supplies you need, and if they are covered by Medicare. The official site for Medicare also has a portal where you can search to see if your service is covered.
Events that are covered by Medicare Part A:
- Inpatient care in a hospital
- Skilled nursing facility care
- Inpatient care in a skilled nursing facility (not custodial or long-term care)
- Hospice care
- Home health care
Part A covered services explained
Medicare covers semi-private rooms, meals, general nursing and drugs as part of your inpatient treatment, and other hospital services and supplies. This includes care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study, and inpatient mental health care given in a psychiatric hospital or other hospital.
This doesn’t include private duty nursing, a television or phone in your room (if there’s a separate charge for these items), or personal care items, like razors or slipper socks. It also doesn’t include a private room, unless medically necessary.
If you have Part B, it generally covers 80 percent of the Medicare-approved amount for doctor’s services you get while you’re in a hospital.
• A deductible and no coinsurance for days 1– 60 of each benefit period.
• Coinsurance per day for days 61– 90 of each benefit period.
• Coinsurance per “lifetime reserve day” after day 90 of each benefit period (up to 60 days over your lifetime).
• All costs for each day after you use all the lifetime reserve days.
• Inpatient psychiatric care in a freestanding psychiatric hospital is limited to 190 days in a lifetime.
Staying overnight in a hospital doesn’t always mean you’re an inpatient. Your doctor must order your hospital admission and the hospital must formally admit you for you to be an inpatient. Without the formal inpatient admission, you’re still an outpatient, even if you stay overnight in a regular hospital bed, and/or you’re getting emergency department services, observation services, outpatient surgery, lab tests or X-rays.
Medicare covers semi-private rooms, meals, skilled nursing and rehabilitative services, and other medically necessary services and supplies furnished in a skilled nursing facility after a three-day minimum, medically necessary, inpatient hospital stay for a related illness or injury.
An inpatient hospital stay begins the day the hospital formally admits you as an inpatient based on a doctor’s order and doesn’t include the day you’re discharged. You may get coverage of skilled nursing care or skilled therapy care if it’s necessary to help improve or maintain your current condition.
To qualify for skilled nursing facility care coverage, your doctor must certify that you need daily skilled care (like intravenous injections or physical therapy) which, as a practical matter, can only be provided in a skilled nursing facility if you’re an inpatient.
• Nothing for the first 20 days of each benefit period
• Coinsurance per day for days 21–100 of each benefit period
• All costs for each day after day 100 in a benefit period. Visit Medicare.gov later this fall to find out what you’ll pay for inpatient hospital stays and skilled nursing facility care in 2019.
Note: Medicare doesn’t cover long-term care or custodial care.
To qualify for hospice care, a hospice doctor and your doctor (if you have one) must certify that you’re terminally ill, meaning you have a life expectancy of six months or less. You must accept palliative care (for comfort) instead of care to cure your illness. You also must sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.
• All items and services needed for pain relief and symptom management
• Medical, nursing and social services
• Certain durable medical equipment
• Aide and homemaker services
• Other covered services, as well as services Medicare usually doesn’t cover, like spiritual and grief counseling
A Medicare-certified hospice usually gives hospice care in your home or the facility where you live, like a nursing home.
Hospice care doesn’t pay for your stay in a facility (room and board) unless the hospice medical team determines that you need short-term inpatient stays for pain and symptom management that can’t be addressed at home.
These stays must be in a Medicare-approved facility, like a hospice facility, hospital, or skilled nursing facility that contracts with the hospice.
Medicare also covers inpatient respite care, which is care you get in a Medicare approved facility so that your usual caregiver (family member or friend) can rest. You can stay up to five days each time you get respite care. Medicare will pay for covered services for health problems that aren’t related to your terminal illness or related conditions.
After six months, you can continue to get hospice care as long as the hospice medical director or hospice doctor recertifies (at a face-to-face meeting) that you’re terminally ill.
• Nothing for hospice care.
• A copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management.
• 5% of the Medicare-approved amount for inpatient respite care.
You can use your home health benefits under Part A and/or Part B.
Medicare coverage is based on 3 main factors
- Federal and state laws.
- National coverage decisions made by Medicare about whether a service is covered.
- Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether a service is medically necessary and should be covered in their area.