As part of our Basics series of presentations, this one was designed to give essential information on Part A, including what it covers and how much it costs.

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Medicare Part A – Qualifications and Coverage

When Medicare was created in 1965, the first two parts offered were A (hospital insurance) and B (medical insurance). The qualifications for these initial programs were fairly simple:

• Age 65 or older

• U.S. citizen or permanent legal resident

• Under age 65 with certain disabilities, like Lou Gehrig’s disease or End Stage Renal Disease (ESRD)

Unbeknownst to many, Part A does have a monthly premium like Part B, but because of some rules surrounding employment and tax history, many beneficiaries do not pay a premium.

• No premium for individuals that have worked at least 40 quarters (10 years) while paying Medicare taxes from their wages. These 40 quarters do not need to be worked consecutively, but cumulatively over their life. If an individual turns 65 and does not have 40 quarters but is still working, once they hit the 40 quarter threshold their premium for Part A will be eliminated

• Worked 0-29 quarters – they’d pay $499/month in 2022

• Worked 30-39 quarters – they’d pay $274/month in 2022

Medicare Part A, also known as hospital insurance, goes above and beyond it’s name to cover many services, including:

• Inpatient hospitalization – NOTE: outpatient hospitalization and/or observation stays are covered under Medicare Part B

• Skilled nursing facility care

• Home health care

• Hospice care

Inpatient Hospitalization Qualifications

Part A covers inpatient hospitalizations if the beneficiary meets both conditions:

• They’re admitted to the hospital as an inpatient after an official doctor’s order, which says they need inpatient hospital care to treat their illness or injury, and

• The hospital accepts Medicare

In certain cases, Part A also covers inpatient hospital care if the hospital’s Utilization Review Committee approves their stay while they’re admitted.

Inpatient Hospitalization Coverage

Medicare-covered inpatient hospital services include:

• Semi-private rooms

• Meals

• General nursing

• Drugs – NOTE: any maintenance medication the beneficiary is currently on cannot be brought into the hospital, and will be administered from the hospital’s in-house pharmacy to the client. These medications, called self-administered drugs, are not covered under Part A nor Part D.

• Other hospital services and supplies as part of their inpatient treatment

Medicare does not cover any of the following during an inpatient hospitalization:

• Private-duty nursing

• Private room (unless medically necessary)

• Television or phone in your room (if there’s a separate charge)

• Personal care items, like razors, slipper socks, etc.

Inpatient Hospitalization Benefit Period

The coverage and costs associated with an inpatient hospital stay are based on what Medicare calls a benefit period. A benefit period begins the day the beneficiary is formally admitted as an inpatient and ends when they haven’t received any inpatient hospital or skilled nursing facility care for 60 days in a row.

For example, if they were in the hospital as an inpatient and were discharged for 30 days then are re-admitted (even if for a different illness/injury), they are still within their previous benefit period and their Medicare benefits would pick up where they left off.

Inpatient Hospitalization Costs

The beneficiary’s costs for each benefit period are:

• $1,556 deductible – this covers them for the first 60 days in the hospital

• Days 1-60: $0 copay

• Days 61-90: $389 copay per day

• Days 91 and beyond: $778 per day

NOTE: These are considered Lifetime Reserve Days. Each beneficiary has a total of 60 Lifetime Reserve Days they can use throughout their life. After those days have been depleted, the maximum days that Medicare will cover for an inpatient hospitalization is capped at 90.

• Each day after Lifetime Reserve days are depleted: the beneficiary would be responsible for all costs

Skilled Nursing Facility Care Qualifications

Medicare Part A covers skilled nursing care in a skilled nursing facility (SNF) for a limited time (on a short-term basis) if all these conditions apply:

• They have part A and have days left in their benefit period to use

• They have a qualifying inpatient stay (3 day minimum, more on that later)

• Their doctor has decided that they need daily skilled care. They must get care from, or under the supervision of, skilled nursing or therapy staff

• They get these skilled services in a Medicare-certified SNF facility

• They need these skilled services for a condition that’s either:

– A hospital-related medical condition treated during their qualifying 3-day inpatient hospital stay (not including the day they were discharged), even if it wasn’t the reason they were admitted to the hospital, or

– A condition that started while they were getting care in the SNF for a hospital-related medical condition (for example, if they develop an infection that requires IV antibiotics while they’re getting SNF care)

Skilled Nursing Facility Care Coverage

Medicare-covered services in a SNF include, but are not limited to:

• A semi-private room (a room they share with other patients)

• Meals

• Skilled nursing care

• Physical Therapy

• Occupational Therapy

• Speech-language pathology services

• Medical social services

• Medications

• Medical supplies and equipment used in the facility

• Ambulance transportation

• Dietary counseling

Skilled Nursing Facility Care Costs

Beneficiaries pay the following for each benefit period (same as inpatient):

• Days 1-20: $0 copay, Medicare covers all charges

• Days 21-100: up to $194.50 per day

• Days 101 and beyond: the beneficiary pays all costs

On page 55 of the 2022 Medicare & You handbook, they specifically state that Original Medicare does not cover the cost of long term care. Medicare will pay for skilled care needed in a facility as part of the recovery from an illness or injury, they will not pay for any long term care services that usually include custodial or non-skilled personal care.

Based on many surveys from Medicare beneficiaries, there is a false expectation that Medicare covers Long Term Care services, that’s why almost an entire page in the Medicare & You handbook is dedicated to dispelling this myth, and is important for beneficiaries to understand.

Home Health Care Qualifications

All people with Part A and/or Part B who meet all of these conditions are covered:

• They must be under the care of a doctor, and they must be getting services under a plan of care created and reviewed regularly by a doctor

• They must be homebound, and a doctor must certify that they’re homebound. Medicare’s definition of “homebound” is based on the following criteria:

Criteria 1 – One of these conditions must be met:

• Because of illness or injury, they need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the user of special transportation; or the assistance of another person to leave their place of residence, or

• Have a condition such that leaving their home is medically contraindicated (not advised by medical professionals)

Criteria 2 – Both of these conditions must be met:

• There must exist a normal inability to leave home, and

• Leaving home must require a considerable and taxing effort

They must need, and a doctor must certify that they need, one of more of these:

•             Intermittent skilled care (other than drawing blood)

•             Physical therapy, speech language pathology, or continued occupational therapy services. The amount, frequency, and time period of these services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively

To be eligible, either: 

•             Their condition must be expected to improve in a reasonable and generally predictable period of time, or

•             They need a skilled therapist to safely and effectively make a maintenance program for their condition, or

•             They need a skilled therapist to safely and effectively do maintenance therapy for their condition

•             The home health agency caring for them must be approved by Medicare

Home Health Care Coverage

Medicare covers all approved home health care services.

Medicare, however, does not pay for:

• 24-hour-a-day care at their home

• Meals delivered to their home

• Homemaker services (like shopping, cleaning, and laundry) that aren’t related to their care plan

• Custodial or personal care that helps them with the activities of daily living, like bathing, dressing, or using the bathroom, when this is the only care they need

Home Health Care Costs

A beneficiary’s costs for Medicare-approved home health care services are:

• $0 for covered services

• After they’ve met the Part B deductible, 20% of the Medicare-approved amount for covered medical equipment in the home (if needed)

This may seem like a generous benefit, but remember, for Medicare to approve the Home Health Care services there are strict limits on coverage for skilled care only, intermittent care, and there must be a reasonable expectation that the beneficiary will improve, and the care will not be needed for an unreasonable amount of time.

Hospice Care Qualifications

Beneficiaries qualify for Medicare-covered hospice care if they have Medicare Part A and meet all of these conditions:

• Their hospice doctor and their regular doctor (if they have one) certify that they’re terminally ill with a life expectancy of 6 months or less, and

• The beneficiary accepts comfort care (palliative care) instead of care to cure their illness, and

• They sign a statement choosing hospice care instead of other Medicare-covered treatment for their terminal illness and related conditions

Hospice Care Coverage

Depending on their illness, their hospice team will create a plan of care that can include any or all of these services:

• Doctor’s services

• Nursing and medical services

• Durable medical equipment and supplies

• Drugs for pain management, spiritual and grief counseling for them and their family

• Any other services Medicare covers to manage their pain and other symptoms

Hospice Care Costs

Medicare beneficiaries generally pay nothing for Medicare-covered hospice care, but there are some costs that can present themselves:

• They pay a copayment up to $5 for each prescription for outpatient drugs for pain and symptom management

• They may have to pay room and board if they live in a facility, like a nursing home, and choose to get hospice care there

• They may pay 5% of the Medicare-approved amount for inpatient respite care o Inpatient respite care is temporary care provided in a nursing home, hospice inpatient facility, or hospital so that a family member or friend who is their primary caregiver can rest or take some time off.

Online Resources

To help beneficiaries find and compare hospitals, nursing homes, and hospice care that are accepted by Medicare, they should visit www.medicare.gov/care-compare. This is a easy to navigate site to see who’s part of the program and how they’re rated.

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