Medicare Part A

How much does Part A cost?

If you have worked and paid into Medicare for at least 40 quarters, then you usually don’t pay a monthly premium for Medicare Part A (Hospital Insurance) coverage if you or your spouse paid Medicare taxes while working. This is sometimes called “premium-free Part A.”

A person who paid Medicare taxes for less than 30 quarters will likely pay $413 a month in 2017.

A person who paid Medicare taxes for 30-39 quarters will likely pay $227 a month in 2017.

Inpatient hospital care

What is covered?

Medicare Part A (Hospital Insurance) covers hospital services, including semi-private rooms, meals, general nursing, drugs as part of your inpatient treatment, and other hospital services and supplies. This includes the care you get in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study, and mental health care.

What’s not covered

Private-duty nursing

Private room (unless medically necessary)

Television and phone in your room (if there’s a separate charge for these items)

Personal care items, like razors or slipper socks

All people with Part A are covered when all of these are true:

A doctor makes an official order which says you need 2 or more midnights of medically necessary inpatient hospital care to treat your illness or injury and the hospital formally admits you.

You need the kind of care that can be given only in a hospital.

The hospital accepts Medicare.

The Utilization Review Committee of the hospital approves your stay while you’re in a hospital.

Your costs in Original Medicare without insurance coverage

$1,288 deductible for each benefit period.

Days 1–60: $0 coinsurance for each benefit period.

Days 61–90: $322 coinsurance per day of each benefit period.

Days 91 and beyond: $644 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime).

Beyond lifetime reserve days: all costs.

***You pay for private-duty nursing, a television, or a phone in your room. You pay for a private room unless it’s medically necessary.

***The copayment for a single outpatient hospital service can’t be more than the inpatient hospital deductible. However, your total copayment for all outpatient services may be more than the inpatient hospital deductible.

***Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

Skilled nursing facility (SNF) care

How often is it covered?

Medicare Part A (Hospital Insurance) covers skilled nursing care provided in a skilled nursing facility (SNF) under certain conditions for a limited time.

Medicare-covered services include, but aren’t limited to:

Semi-private room (a room you share with other patients)

Meals

Skilled nursing care

Physical and occupational therapy*

Speech-language pathology services*

Medical social services

Medications

Medical supplies and equipment used in the facility

Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren’t available at the SNF

Dietary counseling

Medicare covers these services if they’re needed to meet your health goal.

***Medicare covers swing bed services in certain hospitals and when the hospital or critical access hospital (CAH) has entered into a “swing-bed” agreement with the Department of Health and Human Services (HHS), under which the facility can “swing” its beds and provide either acute hospital or SNF-level care, as needed. When swing beds are used to furnish SNF-level care, the same coverage and cost-sharing rules apply as though the services were furnished in a SNF.

***If you’re in a Skilled Nursing Facility but must be readmitted to the hospital, there’s no guarantee that a bed will be available for you at the same SNF if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there’s a cost to hold the bed for you.

Who’s eligible?

People with Medicare are covered if they meet all of these conditions:

You have Part A and have days left in your benefit period.

You have a qualifying hospital stay.

Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. If you’re in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they’re offered.

You get these skilled services in a SNF that’s certified by Medicare.

You need these skilled services for a medical condition that was either:

A hospital-related medical condition.

A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.

Your doctor may order observation services to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you’re getting observation services in the hospital, you’re considered an outpatient—you can’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay. Find out if you’re an inpatient or an outpatient.

Here are some common hospital situations that may affect your SNF coverage:

Situation:

Is my SNF stay covered?

You came to the Emergency Department (ED) and were formally admitted to the hospital with a doctor’s order as an inpatient for 3 days. You were discharged on the 4th day. Yes. You met the 3-day inpatient hospital stay requirement for a covered SNF stay.

You came to the ED and spent one day getting observation services. Then, you were formally admitted to the hospital as an inpatient for 2 more days. No. Even though you spent 3 days in the hospital, you were considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.

Remember, any days you spend in a hospital as an outpatient (before you’re formally admitted as an inpatient based on the doctor’s order) aren’t counted as inpatient days. An inpatient stay begins on the day you’re formally admitted to a hospital with a doctor’s order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day.

***If you refuse your daily skilled care or therapy, you may lose your Medicare SNF coverage. If your condition won’t allow you to get skilled care (like if you get the flu), you may be able to continue to get Medicare coverage temporarily.

Your costs in Original Medicare without insurance coverage

You pay:

Days 1–20: $0 for each benefit period.

Days 21–100: $161 coinsurance per day of each benefit period.

Days 101 and beyond: all costs.

Note

If you stop getting skilled care in the SNF, or leave the SNF altogether, your SNF coverage may be affected depending on how long your break in SNF care lasts.

If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesn’t need to be for the same condition that you were treated for during your previous stay.

If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.

Note

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

Long-term care hospitals

How often is it covered?

Medicare Part A (Hospital Insurance) covers care in a long-term care hospital (LTCH).  LTCHs specialize in treating patients who may have more than one serious condition, but who may improve with time and care, and return home.

Your costs in Original Medicare

Generally, you won’t pay more for care in a long-term care hospital than in an acute care hospital. Under Medicare, you’re only responsible for one deductible for any benefit period. This applies whether you’re in an acute care hospital or a long-term care hospital (LTCH).

You don’t have to pay a second deductible for your care in a LTCH if:

You’re transferred to a LTCH directly from an acute care hospital

You’re admitted to a LTCH within 60 days of being discharged from an inpatient hospital stay

If you’re admitted directly to the LTCH more than 60 days after any previous hospital stay, you pay the same deductibles and coinsurance as you would if you were being admitted to an acute care hospital.

Note

To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service.

Note

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.

Hospice & Respite Care

How often is it covered?

Hospice care is usually given in your home but may also be covered in a hospice inpatient facility. Depending on your terminal illness and related conditions, the plan of care your hospice team creates can include any or all of these services:

Doctor services

Nursing care

Medical equipment (like wheelchairs or walkers)

Medical supplies (like bandages and catheters)

Prescription drugs for symptom control or pain relief

Hospice aide and homemaker services

Physical and occupational therapy

Speech-language pathology services

Social work services

Dietary counseling

Grief and loss counseling for you and your family

Short-term inpatient care (for pain and symptom management)

Short term respite care

Any other Medicare-covered services needed to manage your pain and other symptoms related to your terminal illness and related conditions, as recommended by your hospice team

When you choose hospice care, you’ve decided that you no longer want care to cure your terminal illness and/or your doctor has determined that efforts to cure your illness aren’t working.

***Medicare won’t cover any of these once you choose hospice care:

Treatment intended to cure your terminal illness and/or related conditions. Talk with your doctor if you’re thinking about getting treatment to cure your illness. As a hospice patient, you always have the right to stop hospice care at any time.

Prescription drugs to cure your illness (rather than for symptom control or pain relief).

Care from any hospice provider that wasn’t set up by the hospice medical team. You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness must be given by or arranged by the hospice team. You can’t get the same type of hospice care from a different provider, unless you change your hospice provider. However, you can still see your regular doctor if you’ve chosen him or her to be the attending medical professional who helps supervise your hospice care.

Room and board. Medicare doesn’t cover room and board if you get hospice care in your home or if you live in a nursing home or a hospice inpatient facility. If the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.

Care you get as a hospital outpatient (like in an emergency room), care you get as a hospital inpatient, or ambulance transportation, unless it’s either arranged by your hospice team or is unrelated to your terminal illness and related conditions.

Contact your hospice team before you get any of these services or you might have to pay the entire cost.

Who’s eligible?

If you have Medicare Part A (Hospital Insurance) AND meet all of these conditions, you can get hospice care:

Your hospice doctor and your regular doctor (if you have one) certify that you’re terminally ill (with a life expectancy of 6 months or less).

You accept palliative care (for comfort) instead of care to cure your illness.

You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.

Only your hospice doctor and your regular doctor (if you have one) – not a nurse practitioner that you’ve chosen to serve as your attending medical professional – can certify that you’re terminally ill and have a life expectancy of 6 months or less.

Your costs in Original Medicare without insurance coverage.

$0 for hospice care.

You may need to pay a copayment of no more than $5 for each prescription drug and other similar products for pain relief and symptom control while you’re at home. In the rare case your drug isn’t covered by the hospice benefit, your hospice provider should contact your Medicare drug plan to see if it’s covered under Part D.

You may need to pay 5% of the Medicare-approved amount for inpatient respite care.

Medicare doesn’t cover room and board when you get hospice care in your home or another facility where you live (like a nursing home).

Note

To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service.

Nursing home care

How often is it covered?

Medicare Part A (Hospital Insurance) may cover care given in a certified skilled nursing facility (SNF) if it’s medically necessary for you to have skilled nursing care (like changing sterile dressings). However, most nursing home care is custodial care, like help with bathing or dressing. Medicare doesn’t cover custodial care if that’s the only care you need.

Home health services

How often is it covered?

Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) covers eligible home health services like intermittent skilled nursing care, physical therapy, speech-language pathology services, continued occupational services, and more. Usually, a home health care agency coordinates the services your doctor orders for you.

***Medicare doesn’t pay for:

24-hour-a-day care at home

Meals delivered to your home

Homemaker services

Personal care

Who’s eligible?

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

You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.

You must need, and a doctor must certify that you need, one or more of these:

Intermittent skilled nursing care (other than just drawing blood)

Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the 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: 1) your condition must be expected to improve in a reasonable and generally-predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition.

The home health agency caring for you must be Medicare-certified.

Your must be homebound, and a doctor must certify that you’re homebound.

You’re not eligible for the home health benefit if you need more than part-time or “intermittent” skilled nursing care.

You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.

***Home health services may also include medical social services, part-time or intermittent home health aide services, medical supplies for use at home, durable medical equipment, or injectable osteoporosis drugs.

Your costs in Original Medicare

$0 for home health care services.

20% of the Medicare-approved amount for durable medical equipment.

Before you start getting your home health care, the home health agency should tell you how much Medicare will pay. The agency should also tell you if any items or services they give you aren’t covered by Medicare, and how much you’ll have to pay for them. This should be explained by both talking with you and in writing. The home health agency should give you a notice called the “Home Health Advance Beneficiary Notice” (HHABN) before giving you services and supplies that Medicare doesn’t cover.

***To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service.

***Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.