Medicare Part A

Medicare Part A is the Hospital Insurance (HI) program. Under Part A, fundamental benefits are provided for inpatient hospital care, skilled nursing facility care, home health care, hospice care, and psychiatric hospital care. Though coverage is fairly broad, it is subject to numerous restrictions, limits, and exclusions.

Inpatient Hospital Care
After a Medicare recipient pays an annual deductible ($1,288 in 2016), Medicare Part A pays for all approved services for a hospital stay of up to 60 days. Part A inpatient hospital care covers:

• the costs of a semi-private room
• meals
• regular nursing services
• inpatient prescription drugs
• laboratory tests and X-rays
• use of durable medical equipment, including wheelchairs and walkers
• rehabilitation services, such as physical or occupational therapy

After the sixtieth day and through the ninetieth day of a given hospitalization period, Medicare pays a portion of the costs; the patient is responsible for a daily co-pay. After the ninetieth day, the patient can use a reserve of 60 days (available for one use only), paying a daily co-payment, and Medicare pays the balance. After 150 days of hospitalization, Medicare pays nothing.

Skilled Nursing Facility Care (Nursing Home Benefits)
Medicare Part A covers skilled nursing facility care only if the facility and the patient’s diagnosis and treatment meet certain specified standards. Generally, three requirements must be met:

1. A patient must have first been hospitalized for at least three days before entering the nursing home, and the patient must be admitted to the nursing home within 30 days of being discharged from the hospital.
2. A physician must certify that skilled nursing care is necessary.
3. The patient must use a Medicare-certified facility.

As a result of these strict requirements, many nursing home stays are not covered. For those that are, Medicare pays all covered expenses for the first 20 days; for the next 80 days, the patient is required to pay a daily co-pay. After 100 days, Medicare pays nothing, and the patient is responsible for all charges.

Home Health Care
Under certain conditions, Medicare Part A will cover intermittent or part-time home health care provided by a skilled nurse. Again, Medicare’s requirements for receiving home care are quite strict. Medicare will pay for home health care to treat an illness or injury only if a person meets all of the following requirements:

• A doctor must determine that medical care is needed at home and must make a plan for such care.
• The person needs intermittent skilled nursing care, physical therapy, speech therapy, or occupational therapy.
• The person is home-bound, which means generally unable to leave home (when a person leaves, it must be infrequent and for a short time only, such as to go to a doctor’s appointment).
• The home health care agency must be Medicare-approved.

Keep in mind that unlike Medicare’s nursing home benefit, a person does not need to be admitted to a hospital first in order to qualify for Medicare home health care. In addition, services will be provided on an intermittent or part-time basis only by a visiting nurse, therapist, or home health aide. Medicare’s home health care benefit does not pay for 24-hour full-time care. Medicare generally limits its home health care benefit because the program is only designed to serve individuals who need intermittent care for a relatively short period of time rather than care on a daily basis.
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Once a person is receiving Medicare home health care, his or her plan of care will be reviewed at least every 60 days. If the person’s health changes and care is no longer needed, the home health agency will notify the individual’s doctor, who must then contact Medicare. From that point, home care will no longer be covered by Medicare.

The Medicare home health care benefit will not pay for homemaker services such as housekeeping, shopping, and cleaning. It also does not pay for custodial care—that is, help with meeting daily personal needs such as bathing, toileting, transferring, or eating. Because most people who need long-term care need custodial care, financial practitioners should point out this shortcoming to clients. Many people who do qualify for Medicare home health care benefits still need to pay for additional custodial care in order to live comfortably and independently at home.

Psychiatric Hospital Care
Finally, Medicare Part A pays for inpatient care in a Medicare-participating psychiatric hospital for up to 190 days. At the end of this period, Part A will not pay for any additional inpatient care.

Part A Exclusions
Medicare Part A excludes from coverage:

• personal convenience items (such as telephones and televisions)
• private duty nurses
• custodial care in a skilled nursing facility
• full-time nursing care
• prescription drugs
• homemaker services
• home-delivered meals