Medicare Part A: Eligibility, Coverage, and Cost

Medicare Part A is one portion of the United States federal government program that offers health insurance to seniors and other qualifying individuals.  Part A is:

• available to US citizens age 65 and above, and certain people with disabilities or qualifying diseases
• basic hospital insurance that covers inpatient care in a hospital, skilled nursing facility care, home health care, and hospice care
• subject to a $1600 deductible, as well as various coinsurance/copay costs
• usually provided premium-free (exclusions apply)

Medicare Part A Eligibility

You qualify for Medicare Part A coverage if you fall within one of these two groups of individuals:

• You are age 65 and have paid Medicare taxes for roughly ten years of your life
• You are under age 65 and have a qualifying disability or illness

Eligibility requirements and exclusions are explained in greater detail here.

What Does Medicare Part A Cover?

Medicare Part A is basic hospital insurance that covers inpatient care in a hospital, skilled nursing facility care, home health care, and hospice care.

1. Inpatient Hospital Care

Medicare Part A health insurance will cover inpatient hospital care as long as a doctor orders the stay due to medical necessity, and the hospital accepts Medicare for payment.

Covered hospital services include:

• Semi-private room
• Lab tests
• X-rays
• Operating and recovery room
• Nursing services
• Medications
• Meals
• Special-unit care such as ICU or CCU
• Blood for transfusion after the first three pints (you pay for the first three pints if a free blood bank is not available)

As a Medicare beneficiary, you are responsible for a deductible of $1,600 per benefit period (see below). This means that the first $1,600 of covered Medicare services will be billed to you, before Medicare begins to pay your claims.

Note: A benefit period begins when you’re admitted to the hospital and ends 60 days after discharge as long as no additional hospital services are obtained. You should not incur further expenses for the first 60 days of inpatient care, providing health care providers only order services that are covered by Medicare. After that, coinsurance payments are required for extended stays.

Here is what you can expect to pay for extended hospital stays:

• Days 61-90: $400 per day
• Days 91-150: $800 per lifetime reserve day
• Day 150 and beyond: you pay all costs

2 . Skilled Nursing Facility Care

Medicare Part A will cover short-term skilled nursing facility care that you may require after completing an inpatient hospital stay.  Extended stays are often approved if an infection or another medical condition develops while you are in a skilled nursing facility recovering from an inpatient hospital stay. Your hospital stay must be at least three days, not counting your discharge day, to qualify for skilled nursing facility care.

There is no deductible for care in a nursing home or another skilled nursing facility; however, a coinsurance may be required.

Here is what you can expect to pay for stays in a skilled nursing facility following a hospital stay: 

• Up to 20 days – $0
• Days 21-100 – up to $200 per day
• Day 101 and beyond – you are responsible for all costs

3. Home Health Services

Home health care services include a variety of health care services that may be performed by medical professionals in your home.

Some covered services include:

• Physical therapy
• Occupational therapy
• Skilled nursing care (part-time or intermittent only)
• Osteoporosis injectable drugs
• At-home medical supplies
• Durable medical equipment like wheelchairs
• Home health aide care (part-time only while receiving other skilled nursing services)

Medicare covers these services only if you are certified home-bound and in medical need as determined by a doctor. This care is provided free of charge as long as all services ordered are covered by Part A.

4. Hospice Benefits

Part A hospice coverage differs from all other portions of Medicare because it requires a more emotional commitment from the beneficiary.

To qualify for hospice care coverage, beneficiaries must do the following:

• Accept comfort or palliative care instead of health care services designed to heal and cure
• Sign a document stating that they agree to receive hospice care in place of other services that Medicare might cover

A medical provider must also certify that the beneficiary is terminally ill, defined as having a life expectancy of no longer than six months.

Most hospice care services are covered at 100% by Medicare Part A. Some exceptions include copayments of up to $5 for each prescription ordered for pain management and comfort. In addition, Part A will not cover medications intended to heal or treat medical conditions. Some medications not covered by Part A are covered by Medicare Part D.

Beneficiaries may also pay 5% of respite care received in an inpatient facility while under the care of a hospice team.

What Does Medicare Part A Not Cover?

Medicare Part A certainly covers a lot, but some services are not included.

This list only represents some of the most common exclusions:

• Private room in a hospital or skilled nursing facility
• Routine outpatient screenings and diagnostic procedures
• Private nursing care (inpatient or outpatient)
• Hospital luxuries like telephones and televisions
• First 3 pints of blood for a transfusion (Medigap policies may cover this)
• Skilled nursing facility care without an inpatient hospital stay of at least three days
• Room and board at a skilled nursing facility while receiving coverage for hospice
• Hospital services delivered in “observation” status rather than “admitted” status

If you also receive Medicaid, you may have coverage for some of these expenses. Enrolling in a Medicare Advantage plan or Medicare Supplement plan may also lead to fewer out-of-pocket costs.

How Much Does Medicare Part A Cost?

If you or your spouse have paid Medicare taxes for the required 10 years, you will likely qualify for “premium-free” Part A. This means you will acquire Medicare Part A free of charge.  If you do not qualify under these circumstances, you may still be able to purchase Part A at a premium – subject to other requirements. You must live in the U.S. and show proof of citizenship or legal permanent residency. In this scenario, you will pay a monthly premium for Part A in addition to your Part B premium.

How to Enroll in Medicare Part A

You may choose any of the following options to enroll in Medicare:

• Apply online (this is the fastest option).  As you prepare to apply, use the Medicare Documentation Checklist to gather the information you need in order for the process to go smoothly.
• Call the Social Security Administration toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
• Visit your local Social Security office. The agency has a Social Security office locator on its website.

Note: If you receive disability benefits from Social Security or the Railroad Retirement Board (RRB) for a total of 24 months, you will be automatically enrolled in Medicare Part A when you turn 65. You may also qualify for Original Medicare coverage before turning 65 if you are permanently disabled or have been diagnosed with end-stage renal disease.

If you aren’t automatically enrolled, the best time to do so is during your 7-month initial enrollment period.  If you do not enroll in Medicare Part A during your initial enrollment period (and do not meet the requirements for a special enrollment period), you may face late enrollment penalties.

The initial enrollment period includes the month you turn 65 plus the three months before and after. If you enroll during the three months before your birthday month, your coverage will start on the first day of the month you turn 65. If your birthday is on the first day of the month, then your coverage will start the first day of the month before your birthday month.

Coverage will start the following month if you enroll during your birth month. If you enroll during the three months following your birth month, your coverage starts the first day of the following month.

• Good to Know:

  If you miss your initial enrollment period, you may enroll in Medicare Part A during the annual General Enrollment Period from January 1 through March 31.

Ready to Learn More?

Choosing the right Medicare plan is not a decision that should be taken lightly. With Policy Guide’s assistance, you will have access to the knowledge and expertise of professional agents who can help you compare different health plans, prices, and policies to ensure that you make an informed decision. Let us guide you through this process so that your chosen plan best suits your needs.

Article Resources

• What Does Medicare Part A Cover?
• What Does Medicare Part A Not Cover?
• How to Enroll in Medicare Part A