Most of us know that The Part A program provides compensation for healthcare or medically needed services for hospitalization, however there are certain caps in benefits you should be aware of in order to make precautionary arrangements. To conceptually grasp and understand Part A, you need basic information about the programs payment allocation, for hospitals, nursing facility, or home health care, as well as benefit periods and coinsurance amounts. How much Medicare Part A pays depends on how many days of inpatient care you have during what is called a benefit period or spell of illness.
A benefit period or spell of illness refers to the time you are treated in a hospital or skilled nursing facility, or some combination of the two. The benefit period begins the day you enter the hospital or skilled nursing facility as an inpatient, and continues until you have been out for 60 consecutive days. If you are in and out of the hospital or skilled nursing facility several times but have not stayed out completely for 60 consecutive days, all your inpatient bills for that time will be figured as part of the same benefit period.
Hospital Reimbursement.
Medicare Part A pays only certain amounts of hospitalization for any one benefit period.
The Deductible.
For each benefit period, you must pay an additional amount before Medicare will pay anything. This is called the hospital insurance deductible. The deductible is increased every January.
First 60 Days.
For the first 60 days you are an inpatient in a hospital during one benefit period, Part A hospital insurance pays all of the cost of covered services. However, non-essentials, such as televisions and telephones, are not covered. You pay only your hospital insurance deductible within this time frame. If you are in more than one hospital, you still pay only one deductible per benefit period and Part A covers 100% of all your covered cost for each hospital.
Days 61 - 90.
After your 60th day in the hospital during one spell of illness, and through your 90th day, each day you must pay what is called a coinsurance amount toward your covered hospital cost. Part A of Medicare pays the rest of covered cost.
Reserve Days
Reserve days are a last resort coverage. They can help pay for your hospital bills if you are in the hospital more than 90 days in one benefit period, however the payment is quite limited. If you are in the hospital for more than 90 days in any one spell of illness, you can use up to 60 additional reserve days of coverage. During those days, you are responsible for a daily coinsurance payment. You do not have to use your reserve days in one spell of illness, however you can split them up and use them over several benefit periods. You have a total of only 60 reserve days in your lifetime. Whatever reserve days you use during one spell of illness are gone for good. In the next benefit period, you would have available only the number of reserve days you did not use in previous spells of illness.
Psychiatric Hospitals.
Medicare Part A hospital insurance covers a total of 190 days in a lifetime for inpatient care in a specialty psychiatric hospital. If you are already an inpatient in a specialty psychiatric hospital when your Medicare coverage goes into effect, Medicare may retroactively cover you for up to 150 days of hospitalization before your coverage began. In all other ways, inpatient psychiatric care is governed by the same rules regarding coverage and co-payments as standard hospital care. There is no lifetime limit on coverage for inpatient mental health care in a general hospital. Medicare will pay for mental health care in a general hospital to the same extent as it will pay for other inpatient care.
Skilled Nursing Facilities.
Despite the common misconception that nursing homes are covered by Medicare, the truth is that it only covers a limited amount of inpatient nursing care.
For each benefit period, Medicare will cover only a total of 100 days of inpatient care in a skilled nursing facility. For the first 20 of 100 days, Medicare will pay for all covered cost, which will include all basic services excluding television, telephone, or private room charges. For the following 80 days, the patient is personally responsible for a daily co-payment; Medicare pays the rest of covered cost. Reserve days, available for hospital coverage, do not apply to a stay in nursing facility. After 100 days in any benefit period, you are on your own as far as Part A hospital insurance is concerned. However, if you later begin a new benefit period, your first 100 days in a skilled nursing facility will again be covered.
Home Health Care.
Medicare Part A pays 100% of the cost of your covered home health care when provided by a Medicare approved agency, and there is no limit on the number of visits to your home for which Medicare will pay. Medicare will also pay for the initial evaluation by a home care agency, if prescribed by your physician, to determine whether you are a good candidate for home care. However, if you require durable medical equipment, such as a special bed or wheel chair, as part of your home care, Medicare will pay only 80%.
Hospice Care.
Medicare pays 100% of the charges for hospice care, with two exceptions. First, the hospice can charge the patient up to $5.00 for each prescription of outpatient drugs the hospice supplies for pain and other symptomatic relief. Second, the hospice can charge the patient 5% of the amount Medicare pays for inpatient care in a hospice, nursing facility, or the like every time a patient receives respite care. There is no limit on the amount of hospice you can receive. At the end of the first 90 day period of hospice care, your doctor will evaluate you to determine whether you still qualify for hospice, meaning your disease is still considered fatal and you are still estimated to have less than 6 months to live. A similar evaluation is made after the next 90 day period, and again every 60 days thereafter. If your doctor certifies that you are eligible for hospice care, Medicare will continue to pay for it even if it exceeds the original six month diagnosis. And if your condition improves and you switch from hospice care back to regular Medicare coverage, you may return to hospice care whenever your condition warrants it.
By knowing exactly what Medicare Part A pays, an educated decision can me made as far supplementing the gaps.
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