Must Know Information About Medicare Part A Coverage and Eligibility

Medicare Part A, often known as hospital insurance, covers services and procedures that generally take place in an inpatient setting.

Medicare Part A is known as hospital insurance. This Medicare coverage helps pay for in-patient hospital stays, hospice care, care in a skilled nursing facility, and some home health care needs. You can get Medicare Part A with no premium if you or your spouse has paid into Medicare for a specific amount of time while working.

What Does Medicare Part A Cover?

Medicare Part A covers in-patient hospital stays and other in-patient care. It’s not the coverage you use for doctor’s visits or prescription drugs.

Hospital Coverage

Includes services like semi-private rooms, meals, general nursing and drugs as part of your inpatient treatment.

Hospice Care

Covers care that takes place in a facility or at home. Medicare Part A doesn’t pay for room and board.

Home Health Care

Covers medically necessary services such as:

• Intermittent skilled-nursing care that can be performed at home
• Occupational therapy
• Physical therapy
• Speech-language pathology services

Skilled Nursing Facility Care

Covers skilled nursing services if you need them while you’re a resident, only if all of these conditions are met:

• You have Part A and days left in your benefit period to use.
• You have a qualifying hospital stay.
• You need daily skilled care under the supervision of skilled nursing or therapy staff.
• You need skills services for a medical condition that was treated during your three-day inpatient hospital stay, or a medical condition that began while you received care in the skilled nursing facility.

Note: Medicare Part A won’t cover custodial care, which means you’re living in a nursing home because you need help with activities of daily living (ADLs). In this case, meals, room, and board are not covered by Medicare Part A.

But if you’ve been in the hospital and must transition to a skilled nursing facility, Medicare Part A will cover the cost of your stay, including meals.

Other skilled nursing care costs covered by Medicare Part A include:

• A semi-private room
• Ambulance transportation (when necessary)
• Medical supplies
• Medications
• Speech, physical or occupational therapy

Does Medicare Part A Cover 100 percent?

Most people do not pay a monthly premium for Medicare Part A, although some do. You will have a deductible to cover before Medicare Part A applies, so it does not cover 100 percent. However, once you pay the deductible for inpatient services, you’re covered for the first 60 days. If your in-patient care lasts longer than 60 days, you’ll start paying a coinsurance amount.

What is Not Covered Under Medicare Part A?

Not all medical services are covered by Medicare Part A. Some are covered by other parts of Medicare, such as Medicare Part B and D, and other treatments are not covered by Medicare at all.

Here are the top items not covered by Medicare Part A:

• Long-term care (custodial care), such as a nursing home
• Dental care
• Eye exams related to getting glasses or contact lenses
• Dentures
• Hearing aids or exams
• Cosmetic surgery
• Private-duty nursing
• Private room (unless medically necessary)
• Television & phone
• Personal care items

How Much Does Medicare Part A Cost?

When you're hospitalized, you’ll have to pay a deductible. In 2021, the Part A deductible is increasing to $1,484. This means you’ll pay $1,484 out of your own pocket before Medicare will start paying benefits. This deductible covers you for up to 90 days of inpatient hospital care.

You pay the inpatient hospital deductible each time you're admitted to the hospital, provided you haven't received hospital or skilled nursing facility services within the previous 60-day benefit period. If your hospital stay is longer than 60 days, you’ll begin paying coinsurance for each additional day.

In 2021, you’ll pay:

• $1,484 deductible for each benefit period
• $371 per day for days 61-90 for inpatient hospital stays
• $742 per day for up to 60 “lifetime reserve days” beyond 90 days
• Full cost for every day beyond 90 days when you’ve used up your “lifetime reserve days”

While the deductible and coinsurance payments are calculated for each benefit period, your lifetime reserve days are fixed at 60 for your whole life. This means that you only use a lifetime reserve day if you have a stay of more than 90 days in one benefit period.

If you have a series of hospital stays in different benefit periods, but none of them last more than 90 days, you won’t use any lifetime reserve days - even if your total number of days from multiple benefit periods is more than 90.

If you need more than 20 days of skilled nursing care, you’ll pay:

• $185.50 per day for days 21-100
• Full cost for every day beyond day 100
• There are no “lifetime reserve days” for skilled nursing coverage

Note: Your Medicare part A costs are not capped under Original Medicare, so there is no out-of-pocket maximum like there is for private health insurance. This is a key reason many people consider Medicare Advantage or Medigap plans.

Is Medicare Part A Premium-Free?

Most people don’t pay a monthly premium for Medicare Part A. The coverage is paid for by paying into Medicare during your working years. However, if you or your spouse don’t have an adequate work history of paying Medicare taxes, you may have to pay a premium for Part A.

Who Qualifies for Medicare Part A?

Medicare is health insurance for:

• People who are age 65 or older.
• People under age 65 who are disabled and have received Social Security Disability benefits for at least 24 months.
• People suffering from End Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis, also known as ALS or Lou Gehrig’s disease.

In order to be eligible for Medicare Part A, you must be either:

• A U.S. citizen, or
• A permanent legal resident (living in the U.S. for at least 5 years)

Upon meeting this requirement, most people enter into Medicare when they meet an enrollment milestone, like turning age 65.

Most people who enter Medicare Part A don’t have to pay a premium. If you’ve worked and paid payroll taxes (FICA) for at least 40 quarters, you’re eligible to receive Part A services without a premium.

If you haven’t worked long enough for premium-free Medicare Part A coverage, you may qualify through your spouse. If your spouse qualifies for premium-free Part A, so will you, as long as any of these are true:

• You have been married for at least one year and your spouse is eligible for Social Security benefits.
• You're divorced and your former spouse is eligible for Social Security benefits. (Note: You must have been married at least 10 years, and you must be single now).
• You’re widowed, but were married for at least nine months, and you are currently single.

If you have not paid the FICA taxes or don’t qualify for Medicare Part A through your spouse, you can still enroll in Medicare Part A. In this case, you’ll have to pay the Medicare monthly premium, which is $458 for 2020 and $471 in 2021.

Medicare Part A Coverage Scenarios

Medicare Part A and Working Past Age 65

You can delay your Medicare Part A enrollment if you work past age 65. However, you may want (or need) to enroll in Medicare Part A. In any case, talk to your employer to find out.

If you’re still covered by your employer or spouse’s employer plan, you won’t enroll during your Initial Enrollment Period. Instead, you’ll have a special window to enroll in Medicare whenever your private health coverage ends. You’ll then have 8 months to enroll in Original Medicare.

You also won’t be subject to any late enrollment penalties, as long as you’ve been covered by an employer or your spouse’s employer.

How Does Medicare Part A Work With Disability?

If you become eligible for Medicare due to disability, you'll have a different Medicare enrollment window. Instead, you will be automatically enrolled in Medicare Part A and B on the first day of the 25th month you receive Social Security Disability Insurance.

Note: The requirement for eligibility is 24 consecutive months, but you don’t actually enter Original Medicare until the 25th month.

The same is true if you receive disability income from the Railroad Retirement Board: 24 consecutive months to become eligible and your enrollment occurs on the 25th month.

You can then enroll in a private Medicare plan as soon as you’re enrolled in Part A and B.

Does Medicare Cover ALS?

If you’re diagnosed with Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s disease, the first step to getting Medicare is to apply for Social Security Disability Insurance. You’ll need to indicate that you’ve been diagnosed with ALS on the application.

Then, you’ll automatically enter Original Medicare Part A and B on the first day of the fifth month that you’ve received SSDI payments. Once you’re active in Medicare with Part A and B start dates, you can enroll in a private Medicare health plan, if needed.

Does Medicare Cover End Stage Renal Disease (ESRD)?

The eligibility and entry details for End Stage Renal Disease (ESRD) are often more complicated than other scenarios. But the general rule for ESRD is that your Medicare coverage will begin on the first day of the fourth month of dialysis treatment.

You can enroll in a Medicare Supplement or a Prescription Drug Plan (Part D plan) as soon as you have a Medicare number as well as Part A and B start dates.

Note: Medicare Advantage plans will cover patients with ESRD beginning in 2021. This is great news for ESRD patients because every Medicare Advantage plan has an annual out-of-pocket maximum cap. So once ESRD patients hit their annual spending caps, they’re not required to pay any more medical expenses for the rest of the year.

Read more in our summary of 2021 changes to Medicare.

How To Enroll In Medicare Part A

Your enrollment will be automatic in these situations:

• Turning 65 (aging into Medicare), if you're already receiving Social Security benefits
• Receiving Social Security Disability Income (SSDI) for 24 consecutive months
• Getting diagnosed with End Stage Renal Disease (ESRD), in many cases
• Getting diagnosed with ALS (Lou Gehrig’s disease)

In all of these cases, your Medicare coverage will begin automatically based on applications for other Federal benefits. You shouldn’t have to do anything else to get Part A coverage.

But you’ll have to actively sign up for Medicare in these situations:

• Delaying Medicare past age 65
• Delaying Social Security beyond age 65
• Certain situations for those diagnosed with ESRD

If you'd like to learn more about how to enroll in Medicare Part A, please visit these additional resources:

[Medicare Annual Enrollment period[(https://www.healthinsurance.com/learning-center/article/guide-to-medicare-annual-enrollment-period) When should I apply for Medicare? How to sign up for Medicare at age 65

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