Medicare Part A (Hospital Insurance) Focus Flashcards
Part A covered services - Blood
If the hospital gets blood from a blood bank at no charge, you won’t have to pay for it or replace it. If the hospital has to buy blood for you, you must either pay the hospital cost for the first 3 units of blood you get in a calendar year, or you or someone else can donate the blood.
Part A covered services - Home Health Services
Par A and /or B covers home health benefits.
Part A covered services - Hospice Care
To qualify for hospice care, a hospice doctor and your doctor (if you have one) must certify that you’re terminally ill, meaning you have a life expectancy of 6 months or less. When you agree to hospice care, you’re agreeing to comfort care (palliative care) instead of care to cure your terminal illness. you also must sign a statement choosing hospice care instead of care to cure your terminal illness. You also must sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.
Coverage includes:
- All items and services needed for pain relief and symptom management
- Medical, nursing, and social services
- Drugs for pain and symptom management
- Durable medical equipment for pain relief and symptom management
- Aide and homemaker services
- Other covered services you need to manage your pain and other symptoms, as well as spiritual and grief counseling for you and your family
Medicare-certified hospice care is usually given in your home or other facility where you live, like a nursing home. Original Medicare will still pay for covered benefits for any health problems that aren’t part of your terminal illness and related conditions, but hospice should cover most of your care.
Medicare won’t pay room and board for your care in a facility unless the hospice medical team decides you need short-term inpatient care to manage pain and other symptoms. This care must be in a Medicare-approved facility, like a hospice facility, hospital, or skilled nursing facility that contracts with the hospice.
Medicare also covers inpatient respite care, which is care you get in a Medicareapproved facility so that your usual caregiver (family member or friend) can
rest. You can stay up to 5 days each time you get respite care.
After 6 months, you can continue to get hospice care as long as the hospice
medical director or hospice doctor recertifies (at a face-to-face meeting) that
you’re still terminally ill.
You pay:
* Nothing for hospice care.
* A copayment of up to $5 per prescription for outpatient drugs for pain and
symptom management.
* Five percent of the Medicare-approved amount for inpatient respite care.
Original Medicare will be billed for your hospice care, even if you’re in a
Medicare Advantage Plan. When you get hospice care, your Medicare
Advantage Plan can still cover services that aren’t part of your terminal
illness or any conditions related to your terminal illness. For more on hospice
care and to find Medicare-approved providers, contact your plan or visit
Medicare.gov/care-compare.
Medicare Part A- Inpatient Hospital Care
Medicare covers semi-private rooms, meals, general nursing, drugs (including
methadone to treat an opioid use disorder), and other hospital services and
supplies as part of your inpatient treatment. This includes care you get in
acute care hospitals, critical access hospitals, inpatient rehabilitation facilities,
long-term care hospitals, psychiatric care in inpatient psychiatric facilities,
and inpatient care for a qualifying clinical research study. This doesn’t include
private-duty nursing, a television or phone in your room (if there’s a separate
charge for these items), personal care items (razors or slipper socks), or a private
room, unless medically necessary.
If you also have Part B, it generally covers 80% of the Medicare-approved
amount for doctors’ services you get while you’re in a hospital.
In each benefit period, you pay:
* Days 1–60 (of each benefit period): $0 after you meet your Part A deductible.
* Days 61–90 (of each benefit period): A $400 coinsurance amount each day.
* After day 90 (of each benefit period): An $800 coinsurance amount each day
while using your 60 lifetime reserve days.
After you use all of your lifetime reserve days, you pay all costs.
Part A only pays for up to 190 days of inpatient psychiatric hospital care
provided in a freestanding psychiatric hospital during your lifetime.
Note: Hospitals are now required to include the standard charges for all of their
items and services (including the standard charges negotiated by Medicare
Advantage Plans) on a public website to help you make more informed decisions
about your care
Medicare Part A - Inpatient or Outpatient
Whether you’re an inpatient or an outpatient affects how much you pay for
hospital services and if you qualify for Part A skilled nursing facility care.
* You’re an inpatient when the hospital formally admits you with a doctor’s
order.
* You’re an outpatient if you’re getting emergency or observation services
(which may include an overnight stay in the hospital or services in an
outpatient clinic), lab tests, or X-rays, without a formal inpatient admission
(even if you spend the night in the hospital).
Each day you have to stay, you or your caregiver should always ask the
hospital and/or your doctor, or a hospital social worker or patient advocate, if
you’re an inpatient or outpatient.
Sometimes doctors will keep you as an outpatient for observation services
while they decide whether to admit you as an inpatient or release (discharge)
you. If you’re under observation more than 24 hours, you must get a
“Medicare Outpatient Observation Notice” (also called “MOON”). This notice
tells you why you’re an outpatient (in a hospital or critical access hospital)
getting observation services, and how it affects what you pay in the hospital
and for care after you leave.
Medicare Part A - Religious non-medical health care institution (inpatient care)
If you qualify for inpatient hospital or skilled nursing facility care in these
facilities, Medicare will only cover inpatient, non-religious, non-medical items
and services, like room and board, and items or services that don’t need a
doctor’s order or prescription (like unmedicated wound dressings or use of a
simple walker). Medicare doesn’t cover the religious portion of this type of care.
Medicare Part A - Skilled nursing facility care:
Medicare only covers skilled nursing facility care after a 3-day minimum
medically necessary inpatient hospital stay* (not including the day you leave
the hospital) for an illness or injury related to the hospital stay. Medicare covers
semi-private rooms, meals, skilled nursing and therapy services, and other
medically necessary services and supplies in a skilled nursing facility.
To qualify for skilled nursing facility care, your doctor must certify that you need
daily skilled care (like intravenous fluids/medications or physical therapy) which,
as a practical matter, you can only get as a skilled nursing facility inpatient.
Medicare doesn’t cover non-medical long-term care. Go to page 56.
You may get skilled nursing care or therapy if it’s necessary to improve or
maintain your current condition. If you disagree with your discharge, you can
appeal. For example, if you’re discharged only because you aren’t improving,
but you still require skilled nursing or therapy care to keep your condition from
getting worse, you can appeal.
In each benefit period, you pay:
* Days 1–20: $0 copayment. Note: If you’re in a Medicare Advantage Plan, you
may be charged copayments during the first 20 days.
* Days 21–100: $200 copayment each day.
* Days 101 and beyond: You pay all costs.
*Note: You may not need a 3-day minimum inpatient hospital stay if your
doctor participates in an Accountable Care Organization (ACO), or an entity
participating in another type of Medicare initiative approved for a Skilled
Nursing Facility 3-Day Rule Waiver. If your provider participates in an ACO
(pages 110–111), check with them to find out what benefits may be available.
Medicare Advantage Plans may also waive the 3-day minimum. Contact your
plan for more information.
