U.S. Department of Health and Human Services

published by the Health Care Financing Administration

Medicare Part A Coverage

Benefits Period Home Health Care
Inpatient Hospital Care Hospice Care
Your Right to Appeal Part A Claims
Skilled Nursing Facility Care Medicare Hospital Insurance (Part A) Covered Services for 1997
Blood Coverage

When all program requirements are met, Medicare Part A helps pay for:
· Care in a hospital.
· Care in a skilled nursing facility following a hospital stay.
· Home health care.
· Hospice care.

Benefit Periods

Coverage for care in hospitals and skilled nursing facilities is measured in “benefit periods.” In each benefit period, you are limited as to the number of days Medicare will help pay for inpatient hospital and skilled nursing facility care. Once you exceed the limit, you are responsible for all charges for each additional day of care.

A benefit period begins the day you are admitted to a hospital. It ends when you have been out of a hospital or skilled nursing facility for 60 straight days, including the day of discharge. It also ends if you stay in a skilled nursing facility, without receiving skilled nursing care for 60 straight days.

Once you have ended one benefit period, a new benefit period begins and your hospital and skilled nursing facility benefits are renewed. There is no limit to the number of benefit periods you can have.

Inpatient Hospital Care

If you need inpatient hospital care, Medicare Part A helps pay for up to 90 days of medically necessary care in a Medicare-certified hospital in a benefit period.

In addition, you have 60 lifetime reserve days that are discussed below.

During the first 60 days, Medicare pays all covered costs except for $760. That’s the hospital deductible for 1997, and you are responsible for paying it. You only pay the deductible once during a benefit period no matter how many times you go to the hospital.

For the 61st through the 90th day in a benefit period, Medicare pays all covered costs except for coinsurance of $190 per day in 1997. You are responsible for paying the coinsurance.

Reserve Days

In the unlikely event that you are in the hospital for more than 90 days in a benefit period, you can use your “reserve days” to help pay the bill. You have a supply of 60 reserve days. Once a reserve day is used, it is not renewed. So if you use 10 reserve days, you’ll have 50 left to use during the rest of your life.

When a reserve day is used, Medicare pays all covered costs except for daily coinsurance of $380 in 1997. Again, you are responsible for paying the coinsurance.

Covered Hospital Services

When you are in the hospital, Part A helps pay for a semiprivate room, meals, regular nursing services, rehabilitation services, drugs, medical supplies, laboratory tests, and X-rays. Coverage is also provided for use of the operating and recovery rooms, intensive care and coronary care units, and other medically necessary hospital services and supplies.

Hospital Services Not Covered: Medicare does not pay for personal convenience items such as a telephone or television in your room, for private duty nurses, or for any extra charges for a private room unless it is medically necessary.

Qualifying for Hospital Care: Medicare helps pay for inpatient hospital care when these four requirements are met:

1. A doctor prescribes inpatient hospital care for an illness or injury.

2. Your illness or injury requires care that can only be provided in a hospital.

3. The hospital participates in Medicare.

4. The hospital’s Utilization Review Committee or a Peer Review Organization (PRO) did not disapprove your stay.

Important Message from Medicare: When you are admitted to the hospital for covered care, the hospital is required to give you a copy of a document called An Important Message From Medicare. If you do not get a copy, be sure to ask for one.

The message explains your rights as a Medicare hospital patient. It also tells you what to do if you think you are being discharged from the hospital too early or are notified that Medicare will no longer pay for your hospital care.

Advance Directive: Hospitals also must tell you about your right to prepare an advance directive. An advance directive is a written statement that explains what services you want, or do not want, if you ever become unable to communicate your wishes during a medical emergency.

Involve loved ones and your legal and religious advisers when preparing your advance directive. They can help ensure that your wishes are followed should you become incapacitated. Your doctor also should be consulted and asked to include the advance directive in your medical records. An advance directive is also called a “living will” or “durable power of attorney for health care.”

Skilled nursing facilities, hospices, home health agencies, and HMOs serving Medicare beneficiaries also must give you information about advance directives.

Psychiatric Hospital Coverage: In addition to covering care in a general hospital, Part A helps pay for care in a Medicare-participating psychiatric hospital. Coverage for inpatient services is limited to a lifetime maximum of 190 days of care. Psychiatric care provided in a general hospital is not subject to the 190-day limit. If you are a patient in a psychiatric hospital when you first become entitled to Medicare, there are additional limitations on the number of hospital days that Medicare will pay for.

Christian Science Sanatorium

Part A also helps pay for inpatient hospital and skilled nursing facility services provided by a participating Christian Science sanatorium.

It must be operated or listed and certified by the First Church of Christ, Scientist, in Boston, to qualify for Medicare payment. Medicare will not pay for the practitioner.

Your Right to Appeal

You have a right to appeal many decisions concerning your Medicare benefits. You have this right whether you are part of Medicare fee-for service or you are enrolled in a Medicare managed care plan.

In Medicare fee-for-service, you are entitled to an appeal, in most cases, if you believe Medicare did not pay enough for services or if you believe Medicare has inappropriately denied payment for health care services you received. Any notice of a claim denial will include complete written instructions about how to appeal. For example, if you receive services covered under Part B of Medicare, your appeal rights will be detailed on the back of the Explanation of Medicare Part B Benefits (EOMB) form that is mailed to you. If you want further information on thefee-for-service appeals process, contact the carrier or intermediary that services your state.

In Medicare managed care, you may appeal if your plan denies a service, terminates a service too early, or refuses to pay for services that you believe should be covered. An appeal starts with a reconsideration by the managed care plan. An appeal may also go through a Medicare review and the full Medicare appeals process depending on the circumstances of your case. Additionally, you may be eligible for an expedited or fast decision (within 72 hours) if your health or ability to function could be seriously harmed by waiting for a standard decision. See the managed care plan’s membership materials or contact your plan for details about your Medicare appeal rights.

Whether you are enrolled in fee-for-service or managed care, if you believe you are being discharged too soon from a hospital you have a right to immediate review by the Peer Review Organization (PRO). During the immediate review, you can stay in the hospital at no charge and the hospital cannot discharge you before the PRO reaches a decision.

Another source of information is your state’s insurance counseling program. The phone number for that program is in the resource directory located in this book, starting on page 29.

Skilled Nursing Facility Care

If you need to go to a skilled nursing facility after being discharged from the hospital, Medicare can help pay for your care for up to 100 days in a benefit period.

For Medicare to pay, you must meet the following five conditions:

1. You require daily skilled nursing or rehabilitation services that can only be provided in a skilled nursing facility.

2. You were in a hospital 3 days in a row, not counting the day of discharge, before entering the skilled nursing facility.

3. You are admitted to the facility within a short period of time (generally 30 days) after leaving the hospital.

4. The condition for which you are receiving skilled nursing care was treated in the hospital or arose while you were receiving care for a condition treated in the hospital.

5. A medical professional certifies that daily skilled nursing or rehabilitation care is necessary.

Part A pays the full cost of covered services for the first 20 days. All covered services for the next 80 days are paid by Medicare except for a daily coinsurance amount of $95 in 1997. You are responsible for paying the coinsurance. If you require more than 100 days of care in a benefit period, you are responsible for all charges beginning with the 101st day.

What happens if you are discharged from a skilled nursing facility and later must be readmitted? If you are readmitted within 30 days, Medicare will resume paying for your care until you have used up your 100 days of coverage. The care must be for a condition treated during your previous stay.

If you have been out of the skilled nursing facility 60 or more days and the benefit period has ended, another 3-day hospital stay is required before your skilled nursing facility care benefits are renewed.

A skilled nursing facility is a special kind of facility that primarily furnishes skilled nursing and rehabilitation services. The care must be either performed by or provided under the supervision of licensed nursing personnel or professional therapists.

Not all nursing homes are skilled nursing facilities. Many nursing homes primarily offer custodial care such as help in eating, bathing, taking medicine, and toileting. Medicare does not cover custodial care if that is the only care you need.

If you’re in doubt about whether your stay in a skilled nursing facility will be covered by Medicare, ask your doctor or someone in the facility’s business office. Keep in mind that a skilled nursing facility cannot require you to pay a cash deposit as a condition of admission unless it is clear that your care will not be covered by Medicare.

It is important to know that Medicare pays only a small fraction of the nation’s nursing home bills. Most nursing home bills are paid for with personal funds, purchased long-term care insurance, and by Medicaid, a program for people with low incomes. For more information on paying nursing home bills, contact your state’s insurance counseling program. You will find the phone number in the resource directory of this book.

Blood Coverage

You may need blood as part of a covered inpatient stay in a hospital or a skilled nursing facility-whole blood, units of packed red blood cells, or blood components. If so, Medicare will help pay the costs, including the cost of processing and administering it.

You must either pay for or replace the first three pints of blood, the annual blood deductible. You can replace the blood you use yourself or have another person donate on your behalf.

Both Part A and Part B of Medicare cover blood, and if you meet the three-pint blood deductible under one part you do not have to meet it under the other part.

Home Health Care

If you are confined to your home and require skilled care for an injury or illness, Medicare can pay for care provided in your home by a home health agency. A prior stay in the hospital is not required to qualify for home health care, and you do not have to pay a deductible for home health services.

Medicare Part A (or Part B if you do not have Part A) pays the entire bill for covered services for as long as they are medically reasonable and necessary. If you meet the eligibility requirements for the home health care benefit, Medicare covers part-time or intermittent skilled nursing services, home health aide service, or physical, speech-language, and occupational therapy.

Besides paying for health care services, the home health benefit also covers the full cost of some medical supplies when billed by the home health agency and 80 percent of the approved amount for durable medical equipment, such as wheelchairs, hospital beds, oxygen supplies, and walkers.

Qualifying for Home Health Care: Medicare pays for home health care when these four conditions are met:

1. You require intermittent skilled nursing care, physical therapy, or speech-language pathology.

2. You are confined to your home.

3. Your doctor determines that you need home health care and sets up a plan for you to receive care at home.

4. The home health agency providing the care participates in Medicare.

You can find a Medicare-approved home health agency by asking your doctor or your hospital discharge planner.

Hospice Care

Another benefit available under Part A is hospice care if you become terminally ill. You can elect to receive hospice care rather than regular Medicare benefits for the management of your illness.

Hospice care may be provided by either a private organization or a public agency. With hospice care, the emphasis is on providing comfort and relief from pain. While the Medicare hospice benefit primarily provides for care at home, it can help pay for inpatient care as well as for a variety of services not usually covered by Medicare, including homemaker services, counseling, and certain prescription drugs.

Medicare pays nearly the entire bill for hospice care. There can be a copayment of up to $5 for each drug prescription and about $5 per day for inpatient respite care. Respite care is intended to give temporary relief to the person or persons who regularly assist with home care.

Qualifying for Hospice Care

Medicare pays for hospice care when these three conditions are met:

1. Your doctor and the hospice’s doctor certify that you are terminally ill.

2. You choose to receive hospice care instead of the standard Medicare benefits for the illness.

3. The care is provided by a Medicare-participating hospice program.

If you elect hospice care and later require treatment for a condition other than the terminal illness, you can receive Medicare’s standard benefits. When standard benefits are used, you must pay any required deductibles and coinsurance.

Part A Claims

When you receive services covered by Part A, you do not file a claim for payment. In fact, you seldom, if ever, have to get involved in the processing of a Part A claim.

The hospital, skilled nursing facility, or other provider from whom you received services files the claim for you. It is sent to a private insurance organization called a “Medicare intermediary.” The intermediary has a contract with the federal government to handle Part A claims.

The intermediary will send you a Benefits Notice showing what was billed, Medicare’s portion of the bill, and what you are responsible for paying. All questions about charges and payments should be directed to the intermediary. The intermediary’s address and telephone number appear on the notice.

Medicare Hospital Insurance (Part A)
Covered Services for 1997

Semiprivate room and board, general nursing and other hospital services and supplies. (Medicare payments based on benefit periods; see pg. 10.)

Benefit… Medicare pays… You pay…
First 60 days All but $760 $760
61st to 90th day All but $190 a day $190 a day
91st to 150th day* All but $380 a day $380 a day
Beyond 150 days Nothing All costs

* 60 reserve days may be used only once.

Semiprivate room and board, skilled nursing and rehabilitative services, and other services and supplies. Neither Medicare nor Medigap insurance will pay for most nursing home care.

 Benefit… Medicare pays… You pay…
 First 20 days 100% of approved amount  Nothing
 Additional 80 days Allbut $95 a day Up to $95 a day
Beyond 100 days Nothing All costs

Part-time or intermittent skilled care, home health aide services, durable medical equipment and supplies, and other services.

Benefit… Medicare pays… You pay…
Unlimited as long as you meet Medicare requirements for home health care benefits. 100% of approved amount for services; 80% of approved amount for durable medical equipment. Nothing for services; 20%
of approved amount for durable medical equipment.

Pain relief, symptom management, and support services for the terminally ill.

Benefit… Medicare pays… You pay…
For as long as doctor certifies need. All but limited costs for outpatient drugs and inpatient respite care. Limited cost sharing for outpatient drugs and inpatient respite care.

When furnished by a hospital or skilled nursing facility during a covered stay.

Benefit… Medicare pays… You pay…
Unlimited during a benefit period if medically necessary. All but first 3 pints per calendar year. For first 3 pints.***

*** To the extent the three pints of blood are paid for or replaced under one part of Medicare during the calendar year, they do not have to be paid for or replaced under the other part.

1997 Part A monthly premium: $311 with fewer than 30 quarters of Medicare-covered employment; $187 with 30 or more quarters, but fewer than 40 quarters of covered employment. Most beneficiaries do not have to pay a premium for Part A.

Last Updated December 22, 1997