Life Care Planning: Medicare Part A – Who gets it, what it covers and why it isn’t enough

Attorney Sandra W. Reed

The purpose of this article is to convince seniors eligible for Medicare of the importance of obtaining additional coverage to pay for medical expenses that Medicare does not cover.  Too often individuals opt to rely upon Medicare alone because they erroneously believe that Medicare will pay for all or nearly all of their medical expenses.

Medicare has four parts, each of which covers different types of medical expenses.  Part A primarily pays for inpatient hospital medical expenses while Part B primarily covers outpatient medical services, like doctor’s visits.  Part C is Medicare provided through a Medicare Advantage plan provided by private insurance companies rather than by the government.  These plans generally pay for certain expenses regular Medicare does not.  Part D pays for prescription drugs.

This article will address the coverages and limits to coverage of Medicare, Part A.

Who Gets Medicare Part A?

Those who are receiving Social Security benefits or Railroad Retirement benefits are automatically enrolled in Medicare when they turn 65.  Medicare mails initial enrollment package to those on Social Security retirement 3 months before the month they turn 65.  For those on Social Security disability benefits, the enrollment package goes out during the 25th month of receiving benefits.  All others must enroll themselves.

Those who paid taxes under Federal Insurance Contributions Act (FICA) for at least 10 years will receive Part A premium free.  Those who paid FICA for fewer than 10 years will have to pay a premium to obtain Part A coverage.  Those who do not “buy in” when they are first eligible for Medicare will be subject to a penalty through increased premiums.

What Services Does Medicare Part A Cover?

Inpatient Hospitalization

In general, Part A pays for inpatient hospital expenses but it does not pay for 100% of all services that could be provided.  More specifically Medicare Part A covers a semi-private room, meals, general nursing and other hospital services and supplies.  This includes care in critical access hospitals, inpatient rehabilitation facilities and mental care in psychiatric hospitals, up to a lifetime limit of 190 days.  Drugs received as part of the inpatient treatment are also covered.

However, there are limits on how long Part A pays for inpatient hospital stays.  For each benefit period, a covered patient hospitalized during 2015 will pay a deductible of $1,260.00 for each benefit period.  For the first 1-60 days, the patient pays only the deductible amount.  Then the patient pays $315.00 per day for days 61-90 of a stay and $630.00 per day up to 60 lifetime reserve days.  If a hospital stay last longer than 150 days, the patient pays 100% of the cost of the all days from the 151st day forward.

If Jane Doe has standard Medicare and does not have either Medicare Advantage or supplemental policy and she is hospitalized for 90 days, she will have to pay out of her own pocket $10,710.00 for that stay.  If she remains an inpatient in the hospital for 120 days, her out-of-pocket cost will be $20,160.00 and she will have used 30 of her 60 lifetime days. 

Skilled Nursing Facility Care

Under certain conditions, Medicare Part A will pay for care in a skilled nursing facility (SNF).  The first condition is inpatient hospitalization for a minimum of 3 consecutive days prior to entering the SNF.  Following this hospitalization, the patient must require daily skilled nursing services for a condition which was treated or arose during the hospitalization.  Skilled nursing treatment must begin within a specific time, which is usually 30 days after leaving the hospital.  Additionally, the SNF must be a Medicare-participating facility.

Services Part A pays for in the SNF include a semi-private room, meals, skilled nursing care, physical, occupational and speech-language therapy, medical social services, medications, medical supplies and equipment, dietary counseling and a limited amount for ambulance transportation.

During the first 20 days in the SNF, Part A pays 100% of the costs.  For days 21-100, the patient pays $148.00 a day of the cost and thereafter, all costs.

Home Health Care

If these five requirements are met, Medicare Part A will pay for home health care: (1) the patient is homebound; (2) the skilled care is needed intermittently, rather than constantly; (3) the patient is under the care of a doctor; (4) the patient has had a face-to-face encounter with a doctor prior to treatment; and (5) the home health care agency is Medicare-approved.

If the 5 requirements are met, home health care services are fully covered.  If medical equipment is required, the patient pays 20% of the Medicare-approved amount.  This means that patients may be responsible for more if the provider charges more than Medicare allows.  Medicare does limit the provider to charging no more than 15% more than the Medicare approved amount. 

The home health care plan is reviewed every 60 days to determine if it should continue.

Hospice Care

Medicare Part A will pay for hospice care for those who are terminally ill who are expected to live 6 months or less.  This includes the payment for drugs for pain relief and symptoms management, medical care and support services.  The hospice providers must be Medicare-approved.

A doctor who has a face-to-face encounter with the patient must certify the hospice benefit period.  The first two periods are certified for 90 days.  Thereafter, the benefit period must be re-certified each 60 days. 

Blood

Those insured by Medicare Part A, who require blood as inpatients will not, in most cases, have to pay for or replace the blood provided to them.

Next week this column will address Part B coverage in more depth.

Sandra W. Reed is an attorney with Katten & Benson, an Elder Law firm in Fort Worth, Texas.  She lives in beautiful Somervell County, near Chalk Mountain. If you have questions about this column or wish to suggest a topic of interest, Ms Reed may be contacted by phone at 254.797.0211 or by email at swreed2@yahoo.com.

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