Part A of Texas Medicare
Medicare Made Simple
Medicare Part A
Original Medicare is made of two parts starting with Medicare Part A (which is hospital insurance) and then Medicare Part B (which is medical insurance). Medicare Part A will cover Medicare inpatient care, including care received while in the hospital, a skilled nursing facility, and, in limited circumstances, at home.
Most folks are automatically eligible for Medicare Part A at age 65 if they’re already collecting retirement benefits from Social Security or the Railroad Retirement Board. You can also qualify for Medicare Part A before 65 if you have a disability, ESRD (end-stage renal disease), or ALS (amyotrophic lateral sclerosis). You must be either a US citizen or a legal permanent resident of at least five continuous years.
Generally, Medicare Part A coverage includes*:
- Hospital care (inpatient)
- Home Health Services (limited)
- Skilled nursing facility care, if custodial care isn’t the only care required
- Hospice Care
*Note that some of the above benefits are only covered in limited situations and if certain conditions are met.
Eligibility for Medicare Part A
Generally, you are eligible for Medicare Part A if:
- You are age 65 or older and a United States citizen or permanent legal resident of at least five years in a row.
- You are already receiving retirement benefits.
- You are disabled and are receiving disability benefits.
- You have end-stage renal disease (ESRD).
- You have amyotrophic lateral sclerosis (Lou Gehrig’s disease or ALS).
Most eligible for the Part A of Medicare do not pay a premium if they have worked at least 10 years (40 quarters) and have paid Medicare taxes during that time. Individuals who aren’t eligible for premium-free Medicare Part A can still enroll in Part A but must pay a premium. Beneficiaries who delay enrollment after they first become eligible for Medicare Part A may be subject to a late enrollment penalty once they finally sign up.
Initial Enrollment in Medicare Part A
If you turn 65 and are already receiving your Social Security retirement benefits or benefits from the Railroad Retirement Board (RRB), enrollment in Medicare Part A is usually 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 enrolled in Medicare Part B when you applied for retirement, your Part B coverage will begin at the same time. Your red, white, and blue Medicare card will arrive about three months before your 65th birthday.
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 during your Initial Enrollment Period (IEP). You can do such through the Social Security website, or by visiting a local Social Security office, or by calling 1-800-772-1213 (TTY users 1-800-0778), Mon through Fri, from 7AM to 7PM.
The seven-month IEP begins three months before your 65th birthday, includes the month you turn 65, and ends three months later. The start of your coverage will depend on which month you enrolled during your IEP. Be careful and do not wait until the last minute to enroll. 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.
If you are disabled, enrollment in Medicare Part A hospital insurance (and Medicare Part B medical insurance) will begin after you have been receiving Social Security disability benefits for two years (24 months). The coverage will begin in the 25th month. Your Medicare card usually arrives about three months before coverage begins.
If you have ALS (also known as Lou Gehrig’s disease), your Medicare Part A hospital insurance (and Medicare Part B medical insurance) automatically begins on the same month that your Social Security disability benefits start. Your Medicare card will arrive around one month after you signed up for Social Security disability benefits.
If you have end-stage renal disease (ESRD) and are requiring dialysis, your Medicare effective date is usually the first day of the fourth month of your dialysis treatments. However, you will need to apply for your Medicare benefits; you’re not automatically enrolled if you’re younger than 65.
General Enrollment Period for Medicare Part A
If you delayed enrolling in your Medicare Part A, you may enroll during the next available General Enrollment Period, unless you are eligible for a Special Enrollment period (see below). The General Enrollment Period occurs once each year beginning January 1 and runs through March 31. If you sign up during general enrollment, your coverage will begin on July 1 that year, and your Medicare card will arrive about three months before your coverage begins.
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 late-enrollment penalty when you do sign up.
Special Enrollment Period for Medicare Part A
If you (or your spouse) lose your employer- or union-sponsored group hospital insurance, or if you were a volunteer serving in a foreign country, you may enroll in Medicare Part A immediately or during a Special Enrollment Period (SEP). This is the 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 IEP, you would follow the standard rules for initial enrollment in Medicare Part A. You usually do not have to pay the late-enrollment penalty (if you pay a premium for Part A) if you qualify for an SEP. Your Medicare Part A coverage will begin the first of the month after you enroll, and your Medicare card should arrive within 30 days of your enrollment.
Medicare Part A hospital care coverage
A Medicare Part A beneficiary will receive coverage for hospital expenses that are critical to inpatient care, such as a semi-private room, meals, nursing services, medications that are part of inpatient treatment, and any other services or supplies from the hospital. This includes 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
Also note that Medicare Part A hospital insurance will not cover the costs of a private room (unless deemed medically necessary), private-duty nursing, personal care items like shampoo or razors, or other extraneous charges like television and telephone.
Lastly remember Medicare Part A does not cover the cost of blood. You may not need to pay anything if the hospital gets it from a blood bank at no cost. 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 by someone else or yourself.
Medicare Part A home health care benefits
The Medicare Part A benefit for home health care services are covered when deemed medically necessary and have been ordered by your doctor.
Home health care services usually includes:
- 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
- Durable medical equipment, when prescribed by your doctor*
*If a doctor orders DME (durable medical equipment) as part of your care and the equipment meets the eligibility requirements, the cost is covered separately under Medicare Part B. If you’re eligible for coverage, Medicare will typically cover 80% of the Medicare-approved amount for the durable medical equipment and you pay the remaining 20%.
Medicare Part A will not cover 24-hour home care, meals, or homemaker services if they are unrelated to your treatment. It also won’t cover personal care services, such as help with bathing and dressing, if that is the only care you need.
Medicare Part A does cover the entire cost for covered home health care services. As mentioned above, if you need DME and it’s ordered by your doctor this is covered by Medicare under the Part B and you will be responsible for the 20% of the Medicare-approved amount.
Home health care must be provided by a Medicare-certified home health agency, and a doctor has to certify that you are home-bound. You are “homebound”, according to Medicare, if both of the following are true:
- Under normal circumstances, you cannot leave home and doing so will require substantial effort.
- It is medically inadvisable for you to leave home without the help of another person, transportation, or special equipment.
Medicare Part A nursing home coverage
Skilled nursing facility (SNF) stays will be covered under Medicare Part A after having a qualified hospital inpatient stay for a related illness or injury. To qualify for SNF care, the hospital stay is required to be a minimum of three days, beginning the day you are formally admitted to the hospital as an inpatient. The day you are discharged will not count towards the minimum three-day requirement. The time you spend under observation as an outpatient also will not count towards your qualifying stay.
The skilled nursing care has to be provided at a Medicare-certified facility. Medicare-covered skilled nursing care includes, but is not limited to:
- Semi-private room
- Skilled nursing services
- Rehabilitation services, if they are medically necessary to treat your illness
- Medical social services
- Medications received while in SNF care
- Medical supplies and equipment used in SNF
- Ambulance transportation to nearest provider if needed services are not provided at the SNF
- Dietary counseling
Your doctor must certify that you need daily skilled care that you cannot receive at home, such as intravenous drugs or needed physical therapy. The Part A of Medicare does not cover any long-term care (or personal care, if that is the only care needed).
Medicare Part A hospice coverage
If your doctor certifies that you have a terminal illness with an estimated six months or less to live, you might be eligible for some hospice care coverage. Hospice care focuses on palliative care, not in curing your disease. The goal is to relieve the pain and make the patient as comfortable as humanly possible.
To qualify for Medicare-covered hospice care, all of the following conditions must be met:
- You must be enrolled in Medicare Part A.
- Your doctor or health provider must certify 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, along with any related symptoms or conditions.
- You must receive hospice care from a Medicare-approved hospice care facility.
Medicare Part A hospice care is generally received in the patient’s home. It may include, but is not limited to:
- Doctor services
- Nursing care
- Pain relief medications
- Social services
- Durable medical equipment
- Medical supplies
- 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
If a patient is under hospice care, Medicare Part A might also cover some costs that Medicare normally will not including such things as spiritual and grief counseling. Medicare Part A will only pay for room and board in a hospital if the hospice medical team orders short-term inpatient stays for pain or other symptom management.
Although you must give up any curative treatments for your terminal illness to receive this Medicare coverage, you still have the right to stop the hospice care at any moment. If you are thinking about going back to curative treatments, talk with your doctor.