Original Medicare consists of two parts: Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Medicare Part A covers Medicare inpatient care, including care received while in a hospital, a skilled nursing facility, and, in limited circumstances, at home.
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Video: Medicare & You : Hospice
Eligibility & Enrollment for Medicare Part A
In general, you are eligible for Medicare Part A if:
You are age 65 or older and a U.S. citizen or permanent legal resident of at least five years in a row.
You are already receiving retirement benefits.
You are disabled and receiving disability benefits.
You have end-stage renal disease (ESRD).
You have amyotrophic lateral sclerosis (Lou Gehrig’s disease or ALS).
NOTE: If you do not qualify for Social Security retirement benefits or benefits from the Railroad Retirement Board (RRB) then you must enroll in Medicare Part A manually during your Initial Enrollment Period(IEP). You can do so through the Social Security website, by visiting a local Social Security office, or by calling 1-800-772-1213 (TTY users 1-800-0778), Monday through Friday, from 7AM to 7PM.
Most beneficiaries do not pay a premium for Medicare Part A if they have worked at least 10 years (or 40 quarters) and paid Medicare taxes during that time. Individuals who aren’t eligible for premium-free Medicare Part A can still enroll in Part A and pay a premium.
Beneficiaries who delay enrollment after they first become eligible for Medicare Part A may be subject to a late enrollment penalty once they sign up.
Medicare Part A coverage includes the following:
Hospice care
Hospital care (inpatient)
Limited home health services
Skilled nursing facility care, provided that custodial care isn’t the only care required
NOTE: Please understand that some of the above benefits are only covered in limited situations and if certain conditions are met.
Medicare Part A - Hospice coverage
If your doctor has certified that you have a terminal illness with an estimated six months or less to live, you may be eligible for hospice care coverage. In hospice care, the focus is on palliative care, not curing your disease. The goal is to relieve pain and make the patient as comfortable as possible.
To qualify for Medicare-covered hospice care, you must meet all of the following conditions:
You must be enrolled in Medicare Part A.
Your doctor or health provider must certify that you are terminally ill and have six months or less to live.
You must agree to give up curative treatments for your terminal illness, although Medicare will still cover palliative (comfort-focused) treatment for your terminal illness, along with related symptoms or conditions.
You must receive hospice care from a Medicare-approved hospice facility.
Medicare Part A hospice care is usually received in the patient’s home. It may include, but is not limited to:
Doctor services
Nursing care
Pain relief medications
Social services
Durable medical equipment
Medical supplies
Hospice aide services
Homemaker services
Physical and occupational therapy
Dietary counseling
Short-term inpatient care (if necessary for managing pain or symptoms)
Short-term respite care
If a patient is under hospice care, Medicare Part A may also cover some costs that Medicare normally does not include, such as spiritual and grief counseling. Medicare Part A only pays for room and board in a hospital if the hospice medical team orders short-term inpatient stays for pain or other symptom management.
Although you must give up any curative treatments for your terminal illness to receive Medicare coverage, you have the right to stop hospice care at any time. If you are thinking about going back to curative treatments, talk to your doctor.
Medicare Part A - Home Health care benefits
Medicare Part A benefits for home health care services are covered when deemed medically necessary and ordered by your doctor. Home health care services may include:
Part-time or intermittent skilled nursing care
Physical therapy
Speech-language pathology services
Occupational therapy
Medical social services
Part-time or intermittent home health aide services
Durable medical equipment, when ordered by your doctor*
NOTE: If your doctor orders durable medical equipment as part of your care and the equipment meets eligibility requirements, this cost is covered separately under Medicare Part B. If you’re eligible for coverage, Medicare typically covers 80% of the Medicare-approved amount for the durable medical equipment.
Medicare Part A DOES NOT cover 24-hour home care, meals, or homemaker services if they are unrelated to your treatment. It also does not cover personal care services, such as help with bathing and dressing, if this is the only care that you need.
Medicare Part A covers the entire cost for covered home health care services. As mentioned, if you need durable medical equipment and it’s ordered by your doctor this is covered under Medicare Part B and you are responsible for 20% of the Medicare-approved amount.
The home health care must be provided by a Medicare-certified home health agency, and a doctor must certify that you are home-bound. According to Medicare, you are “homebound” if both of the following are true:
Under normal circumstances, you cannot leave home and doing so would require substantial effort.
It is medically inadvisable for you to leave home without the help of another person, transportation, or special equipment.
Medicare Part A - Hospital care coverage
As a Medicare Part A beneficiary, you will receive coverage for hospital expenses that are critical to your inpatient care, such as a semi-private room, meals, nursing services, medications that are part of your inpatient treatment, and any other services and supplies from the hospital.
This includes inpatient care that received through:
Acute care hospitals
Critical access hospitals
Inpatient rehabilitation facilities
Long-term care hospitals
Mental health care
Participation in a qualifying clinical research study
Medicare Part A hospital insurance DOES NOT cover the costs for a private room (unless medically necessary), private-duty nursing, personal care items like shampoo or razors, or other extraneous charges like telephone and television.
Medicare Part A also does not cover the cost of blood. You do not need to pay anything
if the hospital gets it from a blood bank at no charge. If the hospital does need to
purchase blood for you, you must pay for only the first three units that you receive
each calendar year, unless you have the blood donated by you or someone else.
Medicare Part A Nursing Home coverage
Skilled nursing facility (SNF) stays are covered under Medicare Part A after a qualifying hospital inpatient stay for a related illness or injury. To qualify for SNF care, the hospital stay must be a minimum of three days, beginning on the day you are formally admitted as an inpatient. The day you are discharged does not count towards this minimum three-day requirement. Time spent under observation as an outpatient also does not count towards your qualifying stay.
The skilled nursing care must be provided at a Medicare-certified facility. Medicare-covered skilled nursing care includes, but is not limited to:
Semi-private room
Meals
Skilled nursing services
Rehabilitation services, if they are medically necessary to treat your illness
Medical social services
Medications received while in SNF care
Medical supplies and equipment used in SNF
Ambulance transportation to nearest provider if needed services are not provided at the SNF
Dietary counseling
Your doctor must certify that you need daily skilled care that you cannot receive at home, such as intravenous drugs or physical therapy. Medicare Part A does not cover long-term care (or personal care, if that is the only care you need).
Initial Enrollment in Medicare Part A
General Enrollment Period occurs each year from January 1 to March 31.
If you delayed enrolling in Medicare Part A, you may enroll during the next available General Enrollment Period, unless you are eligible for a Special Enrollment period (see below)
If you sign up during general enrollment, your coverage will begin July 1 of that year, and your Medicare card will arrive about three months before your coverage begins.
If you are not eligible for premium-free Medicare Part A and did not enroll when you were first eligible, you may be subject to a late-enrollment penalty when you do sign up.
Automatic enrollment if you turn 65 and are already receiving Social Security retirement benefits or benefits from the Railroad Retirement Board (RRB), enrollment in Medicare Part A
Benefits begin the first day of the month you turn 65. If your birthday is on the first day of the month, your benefits will begin the month before you turn 65.
If you enrolled in Medicare Part B when you applied for retirement, your Part B coverage will begin at the same time. Your red, white, and blue Medicare card will arrive about three months before your 65th birthday.
The seven-month IEP begins three months before your 65th birthday, includes the month you turn 65, and ends three months later.
The start of your coverage depends on which month you enroll during your IEP.
Be careful not to wait until the last minute to enroll.
If you do not enroll during your seven-month IEP, you will be required to wait until the next general enrollment period (January 1 to March 31) to enroll.
If you are disabled, enrollment in Medicare Part A hospital insurance (and Medicare Part B medical insurance) will begin after you have been receiving Social Security disability benefits for 24 months.
Your coverage will begin in the 25th month. Your Medicare card will arrive about three months before your coverage begins.
If you have ALS (also known as Lou Gehrig’s disease), your Medicare Part A hospital insurance (and Medicare Part B medical insurance) will automatically begin the same month that your Social Security disability benefits begin.
Your Medicare card will arrive about one month after you sign up for Social Security disability benefits.
For end-stage renal disease (ESRD) and require dialysis, your Medicare effective date is usually the first day of the fourth month of your dialysis treatments. H
If you're younger than 65, you need to apply for Medicare benefits because you’re not automatically enrolled
Special Enrollment Period for Medicare Part A
If you (or your spouse) lose your employer- or union-sponsored group hospital insurance, or if you were a volunteer serving in a foreign country, you may enroll in Medicare Part A immediately or during a Special Enrollment Period (SEP).
This is the eight-month period that begins the month after your employment or other group coverage ends (whichever happens first).
If your employment ends during what would be your IEP, you would follow the standard rules for initial enrollment in Medicare Part A.
You usually do not have to pay the late-enrollment penalty (if you pay a premium for Part A) if you qualify for an SEP. Your Medicare Part A coverage will begin the first of the month after you enroll, and your Medicare card should arrive within 30 days of your enrollment.