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Lesson 05: Medicare Part A

Medicare Part A

Medicare Part A, hospital insurance helps pay for inpatient hospital care, limited care within a skilled nursing facility, some home health care and hospice care. For most people, Part A has no monthly fee or premium. This is because you or your spouse paid Medicare taxes while working. If you or your spouse didn`t pay Medicare taxes, you may be able to buy Medicare Part A.

Inpatient Hospital Care Hospital care paid for by Medicare includes semi-private room, meals, general nursing, and other hospital services and supplies (this includes care in critical access hospitals). Medicare does not pay for private duty nursing or for a television or telephone in your room. A private room is not covered unless it is medically necessary. Inpatient mental health care coverage in an independent psychiatric facility is limited to 190 days in a lifetime.

There are 90 renewable hospital days within each benefit period. After the deductible has been paid, Medicare pays for all or part of 90 renewable days of treatment. The "first" 60 days are covered at 100% while days 61-90 require a daily co-insurance payment of $256/day in 2008. Remember a new benefit period does not begin until you have been out of the hospital or nursing home for 60 consecutive days.

If a person is in the hospital beyond the 90 days within a benefit period, he/she begins to use the 60 non-renewable "lifetime reserve" days. These days also require a daily co-insurance payment. Click here for information about Medicare premiums and copayments. 

Once the 60 non-renewable lifetime reserve days have been exhausted, the patient is responsible for the entire bill unless he/she has supplemental insurance that will pay it. Very few people exhaust their lifetime reserve days. However, even if they are exhausted, Medicare would still cover the first 90 days of a new benefit period.

Note: Coverage for hospital care does not include the doctor visits. They would be billed separately.


Early Dismissal from the Hospital

If the patient feels that they have been sent home too soon, they have the right to appeal the hospitals decision and remain in the hospital at no extra charge while the appeal is considered.

The hospital must offer a written Notice of Non-Coverage. If the patient is not given a copy, they should ask for one! To appeal the early dismissal, the patient must contact the Quality Improvement Organization (QIO) for Ohio before noon of the following business day.

Contact:
Ohio KePro
800-589-7337
Rock Run Center, Suite b100
5700 Lombardo Center Drive
Seven Hills, OH 44131


Skilled Nursing Facility (SNF)

Medicare has special limits on coverage for care provided in a Skilled Nursing Facility. The coverage is intended to pay for skilled medical care for a short time between hospitalization and returning home.

Coverage is based upon the following criteria:

  • The patient must be hospitalized for at least three days, not including the day of discharge.
  • The doctor must order daily Skilled Nursing Care or five-days-a-week of skilled therapy for the same condition for which the patient was hospitalized.
  • The patient must enter a Medicare-approved SNF or Rehabilitation Facility no later than 30 days after the day of discharge.

Medicare Part A will pay for up to 100 days per benefit period. The first 20 days are covered at 100% while days 21-100 require a daily co-insurance payment. Visit www.medicare.gov for more information on premiums, coinsurance and copayments.  The nursing home resident must require skilled care for any of the days billed to Medicare. There is no limit on the number of benefit periods during which a person can receive SNF benefits.

Custodial Care in a Skilled Nursing Facility

Most residents in nursing homes need only custodial care because they are unable to perform activities of daily living (bathing, dressing, eating, etc.). Custodial care, for the purpose of meeting personal needs, can be provided by nonprofessionals. The resident requiring only custodial care is not in the nursing home for medical reasons and thus Medicare Part A will not cover this type of care.\


Home Health Care

Home Health Care includes a wide range of visits to deliver skilled medical services to homebound patients. Requirements for Medicare Coverage of Care Medicare Part A will cover home health care if the following criteria are met:

  • The patient must be homebound.
  • The doctor must prescribe a plan of care that includes intermittent skilled nursing care, physical therapy, or speech therapy.
  • The treatment must be performed by a home health care agency that participates in Medicare.
Medicare Payment of Home Care
There is no deductible for home health care, and Medicare pays the home health care agency directly. Medicare pays 100% of all covered and medically necessary home health services under either Part A or Part B, as long as the patient continues to meet the coverage requirements.

Hospice

Hospice Care is provided by a public agency or private organization whose primary role is to provide pain relief and symptom management to terminally ill patients. The aim is not to prolong life, but to make the patient`s final days as comfortable as possible. Medicare has a very generous hospice benefit, so private insurance is usually not needed.

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