There are two parts to Original Medicare: 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 through home health care.
To find out if Medicare covers what you need
- Ask your doctor or health care provider about why you need certain tests, services, items, or supplies, and ask if Medicare covers them. If you need something that’s usually covered and your provider suspects that Medicare won’t cover it in your situation, you’ll have to sign a notice acknowledging that you may have to pay for the item, service, test, or supply.
- Find out if Medicare covers your item, service, or test.
What Part A covers
Medicare covers services and supplies considered medically necessary to treat a disease or condition like lab tests, surgeries, and doctor visits, wheelchairs and walkers.
In general, Medicare Part A covers:
- Hospital care
- Skilled nursing facility care
- Nursing home care (as long as custodial care isn’t the only care you need)
- The entire cost for covered home health care services (when deemed medically necessary and ordered by your doctor)
Home health care services covered by Medicare Part A 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
Home health care must be provided by a Medicare-certified home health agency, and a doctor must certify that you are home-bound. Medicare defines you “homebound” if both of the following are accurate:
- 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.
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, inpatient treatment medications specific for your condition, and any other services and supplies from the hospital, including inpatient care 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 nursing home coverage
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 covers skilled nursing facility (SNF) stays after a qualifying hospital inpatient stay for a related illness or injury. To qualify for skilled nursing facility care, your hospital stay must be a minimum of three days and three nights (required) beginning on the day you are formally admitted as a patient. Time spent under observation as an outpatient 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:
- A semi-private room
- Skilled nursing services
- Rehabilitation services (if they are medically necessary to treat your illness)
- Medications received while in a Skilled Nursing Facility
- Medical supplies and equipment used in a Skilled Nursing Facility
- Medical social services
- Ambulance transportation to nearest provider if needed services are not provided at the Skilled Nursing Facility
- Dietary counseling
Medicare Part A hospice coverage
The focus of hospice care is on relieving pain and to make the patient as comfortable as possible. 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.
To qualify for Medicare-covered hospice care, all of the following conditions must be met:
- You must be enrolled in Medicare Part A (see Eligibility for Medicare Part A below).
- Your doctor must confirm 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 and related symptoms or conditions.
- You must receive hospice care from a Medicare-approved hospice facility.
Medicare Part A hospice care is often received in the patient’s home. It may include, but is not limited to:
- Doctor services
- Nursing care
- Pain relief medications
- 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
- Social services
- Durable medical equipment
- Medical supplies
Medicare Part A pays only for room and board in a hospital if the hospice medical team orders short-term inpatient stays for pain or other symptom management.
If a patient is under hospice care, Medicare Part A may also cover some costs such as spiritual counseling and grief counseling.
What Medicare Part A does not cover
Some of the items and services that Medicare doesn’t cover include:
- Long-term care (also known as custodial care)
- 24-hour home care, meals, or homemaker services if they are unrelated to your treatment
- Personal care services, such as help with bathing and dressing, if this is the only care that you need
- Most dental care
- Eye examinations related to prescribing glasses
- Cosmetic surgery
- Blood (You pay nothing 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 the blood is donated to you.)
- Hearing aids and exams for fitting them
- Routine foot care
- A private room (unless medically necessary)
- Private-duty nursing
- Personal care items like shampoo or razors
- Other charges like telephone and television
If you need services that Medicare doesn’t cover, you must pay for them yourself unless you have other insurance such as a Medigap Insurance Plan or you’re in a Medicare health plan that covers these services. Always ask your insurance provider and/or your doctor to be sure.
Even if Medicare covers a service or item, you usually have to pay a deductible, coinsurance, and/or copayments. A Medigap Insurance Plan can help pay some of the health care costs that Original Medicare (A & B) doesn’t cover, like copayments, coinsurance, and deductibles.
Many people choose to pay the small premium and use their Medigap insurance plan to cover the costs that Medicare doesn’t, providing peace of mind that they’re covered and will not encounter any surprise expenses.
Eligibility for Medicare Part A
Most people 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. But those individuals who aren’t eligible for premium-free Medicare Part A can still enroll in Part A and pay a premium. People who delay enrollment after they first become eligible for Medicare Part A may be subject to a late enrollment penalty once they sign up.
You may qualify for Medicare Part A before age 65 if you have a disability, end-stage renal disease (ESRD), or amyotrophic lateral sclerosis (ALS).
In general, you are eligible for Medicare Part A if any of the following is true:
- You are age 65 or older and are a U.S. citizen or legal resident.
- 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).
Medicare Part A initial enrollment
When you turn 65 and are receiving Social Security retirement benefits or benefits from the Railroad Retirement Board (RRB), enrollment in Medicare Part A is generally automatic.
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 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 (through the , 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) during your Initial Enrollment Period (IEP).
The seven-month IEP begins three months before your 65th birthday, and ends three months after the month you turn 65. The start of your coverage depends on which month you enroll during your IEP. 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 and your coverage will begin July 1 of that year.
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 penalty when you do sign up.
If you are disabled, enrollment in Medicare Part A will begin after you have been receiving Social Security disability benefits for 24 months; your coverage begins in the 25th month.
If you have ALS (also known as Lou Gehrig’s disease) or end-stage renal disease, your Medicare Part A hospital insurance automatically begins the same month that your Social Security disability benefits begin.
If you have end-stage renal disease and require dialysis, the Social Security Administration determines your Medicare effective date.
Medicare Part A Special Enrollment Period
You may enroll in Medicare Part A during a Special Enrollment Period (SEP) if you (or your spouse) lose your employer- or union-sponsored group hospital health insurance, or if you were a volunteer serving in a foreign country, during an 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 Initial Enrollment Period, follow the standard rules for initial enrollment in Medicare Part A (through the Social Security website, by visiting a local Social Security office, or by calling 1-800-772-1213, Monday through Friday, from 7AM to 7PM).
You generally do not have to pay the premium penalty (if you pay a premium for Part A) if you qualify for a Special Enrollment Period. Your Medicare Part A coverage will begin the first of the month after you enroll.