Medicare Part A

Part A covers inpatient hospital stays where the beneficiary has been formally admitted to the hospital, including semi-private room, food, and tests. As of January 1, 2020, Medicare Part A had an inpatient hospital deductible of $1408, coinsurance per day as $352 after 61 days confinement within one “spell of illness”, coinsurance for “lifetime reserve days” (essentially, days 91-150 of one or more stay of more than 60 days) of $704 per day. The structure of coinsurance in a Skilled Nursing Facility (following a medically necessary hospital confinement of 3 nights in row or more) is different: zero for days 1-20; $167.50 per day for days 21-100. Many medical services provided under Part A (e.g., some surgery in an acute care hospital, some physical therapy in a skilled nursing facility) is covered under Part B. These coverage amounts increase or decrease yearly on 1st day of the year.

The maximum length of stay that Medicare Part A covers in a hospital admitted inpatient stay or series of stays is typically 90 days. The first 60 days would be paid by Medicare in full, except one copay (also and more commonly referred to as a “deductible”) at the beginning of the 60 days of $1340 as of 2018. Days 61–90 require a co-payment of $335 per day as of 2018. The beneficiary is also allocated “lifetime reserve days” that can be used after 90 days. These lifetime reserve days require a copayment of $670 per day as of 2018, and the beneficiary can only use a total of 60 of these days throughout their lifetime. A new pool of 90 hospital days, with new copays of $1340 in 2018 and $335 per day for days 61–90, starts only after the beneficiary has 60 days continuously with no payment from Medicare for hospital or Skilled Nursing Facility confinement.

Some “hospital services” are provided as inpatient services, which would be reimbursed under Part A; or as outpatient services, which would be reimbursed, not under Part A, but under Part B instead. The “Two-Midnight Rule” decides which is which. In August 2013, the Centers for Medicare and Medicaid Services announced a final rule concerning eligibility for hospital inpatient services effective October 1, 2013. Under the new rule, if a physician admits a Medicare beneficiary as an inpatient with an expectation that the patient will require hospital care that “crosses two midnights”, Medicare Part A payment is “generally appropriate”. However, if it is anticipated that the patient will require hospital care for less than two midnights, Medicare Part A payment is generally not appropriate; payment such as is approved will be paid under Part B. The time a patient spends in the hospital before an inpatient admission is formally ordered is considered outpatient time. But, hospitals and physicians can take into consideration the pre-inpatient admission time when determining if a patient’s care will reasonably be expected to cross two midnights to be covered under Part A. In addition to deciding which trust fund is used to pay for these various outpatient vs. inpatient charges, the number of days for which a person is formally considered an admitted patient affects eligibility for Part A skilled nursing services.

Medicare penalizes hospitals for readmissions. After making initial payments for hospital stays, Medicare will take back from the hospital these payments, plus a penalty of 4 to 18 times the initial payment, if an above-average number of patients from the hospital are readmitted within 30 days. These readmission penalties apply after some of the most common treatments: pneumonia, heart failure, heart attack, COPD, knee replacement, hip replacement. A study of 18 states conducted by the Agency for Healthcare Research and Quality (AHRQ) found that 1.8 million Medicare patients aged 65 and older were readmitted within 30 days of an initial hospital stay in 2011; the conditions with the highest readmission rates were congestive heart failure, sepsis, pneumonia, and COPD and bronchiectasis.

The highest penalties on hospitals are charged after knee or hip replacements, $265,000 per excess readmission. The goals are to encourage better post-hospital care and more referrals to hospice and end-of-life care in lieu of treatment, while the effect is also to reduce coverage in hospitals that treat poor and frail patients. The total penalties for above-average readmissions in 2013 are $280 million, for 7,000 excess readmissions, or $40,000 for each readmission above the US average rate.

Part A fully covers brief stays for rehabilitation or convalescence in a skilled nursing facility and up to 100 days per medical necessity with a co-pay if certain criteria are met:

A preceding hospital stay must be at least three days as an inpatient, three midnights, not counting the discharge date.

The skilled nursing facility stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay.

If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision (e.g., wound management) then the nursing home stay would be covered.

The care being rendered by the nursing home must be skilled. Medicare part A does not pay for stays that only provide custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc.

The care must be medically necessary and progress against some set plan must be made on some schedule determined by a doctor.

The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment of $167.50 per day as of 2018. Many insurance group retiree, Medigap and Part C insurance plans have a provision for additional coverage of skilled nursing care in the indemnity insurance policies they sell or health plans they sponsor. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 90-day hospital clock and 100-day nursing home clock are reset and the person qualifies for new benefit periods.

Hospice benefits are also provided under Part A of Medicare for terminally ill persons with less than six months to live, as determined by the patient’s physician. The terminally ill person must sign a statement that hospice care has been chosen over other Medicare-covered benefits, (e.g. assisted living or hospital care). Treatment provided includes pharmaceutical products for symptom control and pain relief as well as other services not otherwise covered by Medicare such as grief counseling. Hospice is covered 100% with no co-pay or deductible by Medicare Part A except that patients are responsible for a copay for outpatient drugs and respite care, if needed.