Just because claims are paid by the Part A Medicare Administrative Contractor (MAC), this does not mean claims are paid out of the beneficiaries Part A medical coverage. If a patient has Part A coverage only, Medicare will not pay for services that are performed by a majority of our providers.
Medicare Part A Benefit coverage
Inpatient Hospital Care
Medicare covers up to 90 days of inpatient hospital days in each benefit period (yearly) and an additional 60 lifetime reserve days.
A benefit period begins when a patient is admitted to the hospital and ends when that patient has been out of the hospital for 60 days, or has not received Medicare-covered care in a skilled nursing facility (SNF) or hospital for 60 consecutive days from the day of discharge.
Medicare provides 60 lifetime reserve days of inpatient hospital coverage following a 90-day stay in the hospital. These lifetime reserve days can only be used once — if a patient uses them, Medicare will not renew them. Very few people remain in a hospital for 150 consecutive days. In the rare event this does occur, most Medigap policies contain a benefit for an additional 365 hospital days during a patient’s lifetime. Medigap policies are designed to pay the copayments below; certain policies also pay the deductible.
As of 2016, Medicare requires the following out-of-pocket inpatient hospital costs:
Deductible of $1,288 for the first day as a hospital inpatient. This single deductible covers the next 59 days in the hospital for the same benefit period.
Copayment of $322 per day for days 61-90 (after staying in the hospital for 60 days)
Copayment of $644 per day for days 91-150 (after staying in the hospital for 90 days; these are the 60 lifetime reserve days)
Skilled Nursing Facility (SNF) Care
Medicare covers up to 100 days of care in a skilled nursing facility (SNF) for each benefit period if all of Medicare’s requirements are met, including the need for daily skilled nursing care after three days of prior hospitalization.
Medicare pays 100% of the first 20 days of a covered SNF stay. A copayment of $161 per day (in 2016) is required for days 21-100 if Medicare approves the stay.
Home Health Services
Medicare covers up to 100 home health visits per period of illness following a hospital stay. Additional home health benefits are available under Part B. Home health visits under both Parts A and B must meet the following conditions:
- A physician has certified the patient as homebound
- Intermittent skilled nursing or therapy services are required
- Services are provided by a Medicare-certified home health agency
Hospice Care
Hospice care is available for terminally ill patients. The goal of hospice care is to keep the patient as comfortable as possible. It does not provide treatment for the terminal illness.
Medicare Part B Benefit Coverage
- Doctors’ services
- Outpatient hospital care
- Laboratory tests
- Outpatient physical therapy
- Outpatient speech therapy
- Certain home healthcare
- Certain ambulance services
- Certain medical equipment and supplies
- FQHC/RHC visits
Part B coverage is optional. If beneficiary or spouse is still working and covered by employer group health plan, Part B may not be needed until the beneficiary or spouse retire.
The standard Medicare Part B premium for 2016 is $121.80.