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Medicare Part C: Medicare Advantage Plans

by | August, 2017 | Medicare Advantage

     In addition to Part B, Part A is one of two parts which make up Original Medicare.  Part A typically provides coverage for in-patient care.  This means care that is provided to individuals while they are patients admitted into an in-patient facility such as a hospital, rehab, or skilled nursing facility. For this reason, Part A is sometimes referred to as Medicare’s “hospital insurance.”

What Medicare Part A Covers

Calling Part A “hospital insurance” is somewhat misleading since Part A does not cover all the services provided in the hospital.  For example, it doesn’t cover the fees charged by doctors who participate in your care while you’re in the hospital. Medicare Part B helps pay those costs.

In addition, Part A does cover some services outside the hospital such as skilled nursing care performed at home under certain circumstances and services provided under hospice care for those who are terminally ill. However, in general, if you have Original Medicare and you are admitted as an inpatient into an acute care hospital, a critical access hospital, a psychiatric hospital, or an inpatient rehabilitation facility, it is likely that Part A is paying most of the bill.

Check out the chart below for a breakdown of the services covered under Part A:

When Medicare Part A Applies

Several criteria must be in effect for Part A to apply. The first criteria is that you need the kind of care that can be given only in a hospital. Thankfully, many more procedures can now be done on an outpatient basis. Those are covered under Medicare Part B. However, Part A is there to cover serious care that requires hospitalization.

The next qualification is hospital admittance for more than one night.  A doctor must make an official order which says you need 2 or more midnights of medically necessary care to treat your illness or injury, and the hospital formally admits you. Staying in a hospital overnight just for observation does not meet criteria for services to be covered under Part A.  You will still have insurance to help with those costs, but those costs will be covered under your Part B coverage.

Another requirement for Part A coverage is that the hospital must accept Medicare. Fortunately, most standard hospitals do.

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Finally, the Utilization Review Committee of the hospital approves your stay while you’re in a hospital. The hospital medical staff will discharge you once they feel it is medically safe for you to return home.  With scenic Florida views from your high-rise window, a nurse at your beck-and-call, and on-demand movies at the touch of a button, you may not want to return to a world where you have to make your own coffee.  But, once the doctors determine that you no longer need hospital services, Part A will stop picking up the tab.  At that time, if you still need continued care, you’ll receive it on an outpatient basis covered under Medicare Part B.

What Part A Does Not Cover

Private Duty Nursing

Even for the seriously ill, a round-the-clock personal nurse is not covered by Medicare.

Private Room

Unless medically necessary, if your hospital charges extra for a private room, Medicare will not cover the extra charge.

TV & Phone

If your hospital charges extra for these services, medicare will not cover the extra charges.

Personal Care Items

These include razors, shaving cream, or slipper socks. If your hospital charges extra for these, Medicare will not cover the extra charges.

What Part A Costs

Medicare was never intended to cover 100% of your healthcare expenses. It does require you to share some costs.  Below is a breakdown of some of the costs you can expect if you are enrolled in Original Medicare.  These costs may be different for you if you have enrolled in a Medicare Advantage plan.

Premium

Most people automatically receive Part A without having to pay a monthly premium. This is because, if a person has worked for the required length of time, forty quarters or ten years, the Medicare payroll taxes deducted from their income has essentially prepaid for their enrollment in the program.

If someone has not worked at least ten years or has not had withholding for Medicare tax during their working years, they will pay a premium for their Part A coverage. The standard Part A premium for someone who has had Medicare withholding for 30-39 quarters is $232 per month, and the standard Part A premium for someone who has had Medicare withholding for less that 30 quarters is $422 per month.  Medicare may also adjust the premium for those with higher incomes.

Part A Premium Dollar Amounts

Standard Monthly Part A Premium Amount if You Paid Medicare Taxes for at Least 10 Years

Standard Monthly Part A Premium Amount if You Paid Medicare Taxes for at Least 7.5 Years

Standard Monthly Part A Premium Amount if You Paid Medicare Taxes for Less Than 7.5 Years

Deductible

$1,340

Hospital Deductible

If you have Original Medicare Part A and are admitted to a hospital, you must pay a deductible. You are responsible for the first $1,340 of your bill for each benefit period.

Copayments

Hospital

Days 1-60:      $0 per day of each benefit period

Days 61-90:    $335 per day of each benefit period

Days 91 and beyond:     $670 per day up to sixty lifetime reserve days

After you’ve used all 60 lifetime reserve days, you pay all costs.

Skilled Nursing Facility

Days 1-20:      $0 per day of each benefit period

Days 21-100:      $168 per day of each benefit period

Days 101 and beyond:     You pay all costs.

Hospice

Medications for pain and symptom management:      Up to $5 per prescription

Durable medical equipment used at home:      20% of the cost

Respite care:      5% of the Medicare-approved amount

Key Terms

Premium:  A premium is a periodic payment you make to an insurance provider for your coverage. Most people are billed monthly or quarterly.  In the case of Medicare,  the premium is usually automatically withdrawn from your monthly social security benefit.

Deductible: A deductible is an amount that you must pay before your insurance will be applied.

Copayment: A copayment, usually called a  “copay,” is a dollar amount that you must pay as your share of the cost for a particular medical service after you have paid your deductible.

Benefit Period:  In Medicare Part A, a benefit period begins the day you go into a hospital or skilled nursing facility. It ends when you have been out for 60 days in a row. You may be in the hospital more than once during one benefit period. There is no limit on the number of benefit periods that Medicare will cover. Part A charges a deductible for each benefit period.

Lifetime Reserve Day:  In Medicare Part A, a set number of covered hospital days you can draw on if you are in the hospital longer than 90 days in a benefit period. You have 60 lifetime reserve days. A lifetime reserve day cannot be replaced. When it is used up, it is gone.

Medicare Approved Amount: The amount Medicare determines to be reasonable for a covered service. Providers who “accept assignment” agree to accept this amount as payment in full. Providers who accept Medicare but not assignment can charge up to 15% above this amount.

Recap

Part A is one of two parts which make up original Medicare. It provides coverage for hospital stays and other inpatient facilities such as psychiatric hospitals and rehabilitation centers.  Part A also applies to limited home health care services and end-of-life hospice care.

While Medicare Part A covers a lot, it does not cover long-term custodial care or private duty nursing. Also, if you are at a hospital that charges extra for services such as television, telephone, or personal care items, Medicare will not cover the extra charges. Under Medicare, you’ll still have some cost sharing such as deductibles and copays. You may be able to offset some of these costs by enrolling in a Medicare Advantage or Medicare Supplement plan.  When you are ready, talk to a licensed agent about these options.

Now, you know a little more about the coverages and cost responsibilities of Original Medicare Part A. Remember that the inpatient care coverage offered by Part A is supplemented by outpatient coverage provided under Part B.

To learn more about the services and charges under Part B. Click on the section below.

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