Not everyone can enroll in Medicare Part A. If you enroll, you may or may not have to pay a premium, depending on which of the categories below you belong to.
You are eligible for free enrollment in Medicare part A (without having to pay a premium) if any of the following apply to you:
- You are age 65 or older, and you are eligible to receive social security retirement or survivors benefits or railroad retirement board benefits;
- You are under age 65, and you are entitled to receive social security disability benefits or railroad retirement board disability benefits and have been entitled to those disability benefits for at least 24 months;
- You are under age 65, you have kidney disease requiring dialysis or kidney transplant, have been diagnosed with ALS, and you are insured for Social Security benefits, or you are the spouse or dependent child of someone who is insured for social security benefits.
Enrollment with a premium
If you do not meet one of the above conditions, you may still be able to enroll in Part A, but you will have to pay a large monthly premium.
You can enroll with a monthly premium if either of the following applies:
- You are over age 65, and either a US citizen or an alien lawfully admitted for permanent residence which has been present in the US for at least 5 years; or
- You are a person with disabilities who has stopped receiving Social Security Disability benefits because of your employment income.
As of January 2017, the premium cost is $413 per month for people not eligible to enroll for free, and who have less than 30 quarters of Medicare-covered employment. The price is $226 per month for people having 30-39 quarters of Medicare-covered employment. A quarter is 3 months in a year.
You do not need to file a claim for coverage of a Medicare Part A covered service. Instead, the hospital, nursing home, or other provider submits the claim.
You will then receive a Benefits Notice explaining how much was paid and the amount you are responsible for paying.
Services covered under Part A include care provided in an inpatient hospital, a psychiatric hospital, or a skilled nursing facility, as well as hospice care and home health care.
Centers for Medicare and Medicaid Services (CMS) issues a handbook called Medicare & You that contains a thorough summary of covered services.
Inpatient Hospital Care
Medicare covers the costs of hospital care if your doctor required the hospitalization to treat an injury or illness, and hospitalization was medically necessary.
To understand how Medicare covers inpatient hospital care, you must understand benefit periods. A benefit period begins the day you enter the hospital and ends when you have been out of the hospital or skilled nursing facility for 60 straight days. Once a benefit period ends, a new benefit period begins upon a new admission to a hospital.
There is no limit to the number of benefit periods you can have. But Part A will only pay for up to 90 days of inpatient hospital care during a single benefit period. Also, you have 60 lifetime reserve days that can be used to cover days beyond the 90th day.
During the first 60 days of hospitalization, Medicare pays the entire costs, and you pay a $1,316 deductible and no coinsurance for days 1– 60 of each benefit period.
During the 61st to the 90th days, you must pay a coinsurance amount. As of 2017, this amount is $329 per day. During any lifetime reserve days used beyond the 90th day, your coinsurance amount is higher, and as of 2017, is $658 per day. Unless you have supplemental insurance, you are responsible for all costs beyond your lifetime reserve days.
Part A pays for the following things:
- A semi-private room, meals
- Regular nursing and rehabilitation services
- Drugs and medical supplies administered during the hospital stay
- Lab tests
- Operating and recovering rooms
- Intensive care, and
- Other medically necessary services provided while you’re in the hospital
Medicare does not cover:
- Personal convenience items
- Telephone use or private duty nursing, or
- Extra charges for a private room (unless medically necessary)
Psychiatric hospital care
Medicare helps pay for mental health services given in a hospital that require you to be admitted as an inpatient. These services can be provided in a general hospital, or in a psychiatric hospital that only cares for people with mental health conditions.
There’s no limit to the number of benefit periods you can have when you get mental health care in a general hospital. You can have multiple benefit periods when you get care in a psychiatric hospital, but there’s a lifetime limit of 190 days.
As of 2017, you pay:
- $1,316 for each benefit period,
- $0 deductible for days 1–60 of each benefit period
- $329 per day coinsurance payment for days 61–90 of each benefit period, and
- $658 per day coinsurance for each lifetime reserve day after day 90 of each benefit period. For mental health insurance add 20% of the Medicare-approved amount.
Skilled nursing facility care
Medicare covers medically necessary care in a skilled nursing facility (SNF) if:
- You were hospitalized for at least 3 days in a row, not counting the day of discharge, before entering the nursing facility;
- You’re admitted to the facility shortly after leaving the hospital (usually within 30 days); and
- The condition for which you are in the nursing facility was treated or arose while you were hospitalized.
Part A pays for the full cost of the first 20 days in an SNF. During the 21st to the 100th day, you must pay coinsurance. As of 2017, the amount is $164.50 per day. Medicare does not cover any days beyond the 100th day.
If you leave the skilled nursing facility and are then re-admitted within 30 days for treatment of the same condition, Medicare will resume coverage up to the 100th day.
Medicare covers hospice care if you are terminally ill. Terminally ill means that a doctor certifies that the life expectancy of a patient is no more than 6 months. The care is usually provided in your home and inpatient respite care is covered. Medicare covers homemaker services, counseling, and some prescription medications under the hospice benefit.
Home health care
To be eligible for home health care services, you must be confined to your home, and your doctor must establish a care plan. Medicare covers the following home health care items:
- Part-time or intermittent skilled nursing services
- Home health aide service
- Physical, speech-language, and occupational therapy
- Medical supplies provided by the home health agency
Medicare covers 80% of durable medical equipment needed to enable you to remain in the home and all of the cost for home health care services. It is important to note that the rate at which home health care agencies are reimbursed has recently been significantly reduced. As a result, it may be difficult for a Medicare beneficiary to locate a provider of home health care services.
You may also qualify for a personal attendant or other home services under various state programs, such as
Updated: December 2016