Does Medicare Cover Hospital Visits?
This article was updated on: 09/10/2018
Original Medicare is a federal health insurance program managed by the Centers for Medicare & Medicaid Services (CMS). It provides health-care benefits for American citizens and permanent legal residents (of at least five years in a row) aged 65 or older. Medicare also covers some people younger than 65 who might qualify for Medicare due to certain disabilities or health conditions.
Original Medicare is made up of two parts, Part A and Part B.
- Medicare Part A (hospital insurance) may cover certain costs if you are admitted to a hospital, skilled nursing facility, or hospice program. It may also cover limited home health services (usually short-term).
- Medicare Part B (medical insurance) may cover outpatient care, physician services, durable medical equipment and supplies, and certain preventive medical services and diagnostic tests.
Medicare Part A generally helps pay for hospital inpatient care. For each benefit period, Medicare typically pays:
- All covered costs except the Part A deductible during the first 60 days
- Coinsurance amounts for hospital stays from 61 to 90 days
After 91 days, a coinsurance amount usually applies for each “lifetime reserve day.” You may get up to 60 lifetime reserve days during your lifetime.
What services are included in hospital inpatient care coverage?
Let’s start by looking at the kind of inpatient care settings that may be covered by Medicare Part A. These include:
- Acute care medical hospitals, which provide medically necessary care for an illness or injury
- Long-term care hospitals, which generally specialize in treating multiple serious health conditions for those who are expected to improve with time and care, and return home
- Psychiatric hospitals, which provide medically necessary care for a behavioral issue or mental illness
- Skilled nursing and rehabilitation facilities, which provide medically necessary care for an illness or injury that requires full-time, temporary nursing and/or rehab care (such as physical or speech therapy)
Medicare Part A generally covers hospital services, including semi-private rooms, meals, nursing care and medications given as part of your inpatient treatment, and other hospital services and supplies.
However, Medicare does not pay for everything associated with inpatient care, and there may be cost-sharing for covered services, as described below.
What do you pay for hospital inpatient care under Medicare Part A?
You will generally be responsible for paying a portion of the inpatient care that Medicare Part A does not pay. Let’s break down these expenses.
- Deductible: This is an amount you have to spend before Medicare starts to pay for covered services. The deductible amount may change from year to year.
- Coinsurance: This is the part of the Medicare-approved costs for hospital care you may be required to pay after you’ve met your deductible.
- Non-covered services: These include hospital services that you request or perhaps your doctor orders that are not covered under Medicare Part A. Examples of non-covered services may include (but are not limited to) such things as:
- Convenience items like razors
- Custodial care, if this is the only care you need. This care can be given by someone who is not medically skilled–help with dressing, walking, or eating are examples.
- Private-duty nursing care
- A private room
- Inpatient days beyond the Medicare Part A coverage maximum number of days in a benefit period (explained below)
Now, let’s look at when you may incur these expenses.
Your Medicare Part A deductible is tied to a benefit period. A benefit period begins on the day you’re admitted to a hospital as an inpatient, and ends when you’ve been out of the hospital for 60 days in a row. So if you’ve left the hospital on a certain day, and are then readmitted as an inpatient before 60 days from that date, you’re still within the same benefit period. But if you go back into the hospital after that 60th day, you’re in a new benefit period and will need to pay the Part A deductible again before Part A covers services. Note that time spent in a skilled nursing facility—where you may go for continuing skilled nursing care or rehab services after you leave the hospital—generally counts toward a benefit period.
Here is what you pay and what Medicare pays for hospital care in each separate benefit period.
- You are responsible for the Medicare Part A hospital deductible ($1,340 in 2018), which applies to each new benefit period. You must pay the deductible before Medicare Part A covers services you received in the hospital.
- Once you’ve paid the deductible, Medicare picks up the rest of the tab for covered acute hospital care (bed, meals and nursing services) for a stay of up to 60 days after admission. If you stay in the hospital for the entire 60 days, or are discharged sooner but return during the same benefit period (even for a different medical problem), you pay nothing further for the hospital stay. (But you may pay for physicians’ care and certain other services under your Medicare Part B benefits—usually 20% of the Medicare-approved costs.)
- If you need to spend more than 60 days in the hospital—whether consecutively or because of a readmission—during the same benefit period, you will pay a daily coinsurance for days 61 through 90. This coinsurance is set annually ($335 in 2018) and appears in your Medicare benefit coverage booklet.
- After 90 days of Medicare-covered inpatient hospital care in the same benefit period, you are generally responsible for 100% of the costs. However, Medicare allows you a further 60 days of “lifetime reserve” days. This means that for the rest of your life you can draw on any of these 60 days—but no more—to extend Medicare coverage in any benefit period.
Once you’ve been out of the hospital for 60 days in a row, you start a new benefit period if you need to be admitted again. With each new benefit period, you get the same benefits and pay the same set of charges as described above, depending on how long you need hospital care.
There is no limit to the number of benefit periods you can receive in general acute care hospitals for inpatient care. However, if you are hospitalized in a specialized hospital for mental health care, Medicare covers only 190 inpatient psychiatric days in your lifetime.
Hospital stay and skilled nursing facility care
Under the Original Medicare program, you must be admitted and spend at least 3 days in the hospital as an inpatient before Medicare will cover your stay in an approved skilled nursing facility (SNF) for further care. The time spent in both the hospital and the SNF count toward a benefit period. And you must have stayed out of both for 60 days to qualify for a new benefit period.
Your share of the costs in a skilled nursing facility is different from your share of the costs for hospital care. In a skilled nursing facility, in any one benefit period you pay:
- Nothing for your bed, board and care for days 1 through 20
- A daily coinsurance of $167.50 in 2018 for days 21 through 100
- All charges beyond 100 days
You can’t use hospital lifetime reserve days to extend Medicare coverage in a skilled nursing facility beyond 100 days in any one benefit period.
Note that you may be able to sign up for a Medicare Supplement (Medigap) plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.
Hospital stay coverage under Medicare Advantage
You may choose to receive your Medicare Part A and Part B coverage through a local Medicare Advantage plan. Medicare Advantage plans are offered by private insurance companies that are approved by Medicare and cover at least the same level of benefits as Original Medicare Part A and Part B (with the exception of hospice care, which is covered under Medicare Part A). Many Medicare Advantage plans cover extra benefits beyond Original Medicare.
Keep in mind that Medicare Advantage plans have some flexibility in setting their rates and charges; you may be responsible for a monthly plan premium, deductibles, and/or copayments or coinsurance. (You also still have to pay your Medicare Part B monthly premium, regardless of whether your Medicare Advantage plan includes a premium.) Under a Medicare Advantage plan, you may need to receive care from hospitals and doctors participating in the plan’s network. Consult your Medicare Advantage plan or benefit information for coverage details.
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