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Medicare Part A: The Basics

Updated: Sep 21, 2023

By Martine G. Brousse

"The Medical Bill Whisperer"

Patient Advocate, Healthcare Specialist, Certified Mediator

AdvimedPro


September 7, 2023


Watch the YouTube video:


Medicare has many parts: A,B,C,D

This blog addresses part A, a first in a serie of 4


So, what services does Part A cover?

At what cost to patients?

Are there restrictions or limitations?


First, those of you with a Medicare Advantage plan, be aware that although your plan must cover the same services, special coverage rules may apply.



A. The Benefit Period


This is what defines how much your cost will be. Why? Because your share of cost changes according to how long you or your loved one needs to remain inpatient in a facility.


1. The day of admission to any medical or mental health facility, hospital or skilled nursing facility, the clock starts running. That means Medicare starts making payment on your behalf.

Yes, you first have to pay the deductible: $ 1,600.00 in 2023.


If you are discharged less than 2 months later, you must wait 60 days from that day before a new benefit period starts again, and benefits resume.


As an example, let’s say you become inpatient in a hospital on March 1. Your benefit period starts March 1.

If you are discharged on March 15, that benefit period will end 60 days later, on May 14.


2. If you stay in a hospital for more than 60 days, Medicare will stop paying 100% - but still pay something - and the balance will be your responsibility.


3. We’ll see later what happens after 90 days.


4. The good news: there is no limit to benefit periods in your lifetime

The less good news: you must pay the deductible each time



B. Part A covers costs for 5 major areas:

By order of importance:


· Part A covers what the hospital or facility bills for: use of a bed, meals, use of the nursing staff, medications and supplies, use of the operating room, use of equipment, etc.


· You will pay $ 1,600.00 in 2023 for the deductible, nothing until day 60 then $400.00/day between day 61 and 90.


· After 90 days, your cost doubles and another countdown starts. You get 60 “reserve days” per lifetime. Once these are used, whether at one time or over several years, Medicare stops paying, and you will be responsible for 100% of the cost.


2. Skilled Nursing Facility (SNF)

· Usually this is where you get transferred if you are not sick enough to stay in a hospital, but not well enough to go home.


· Medicare covers the use of a bed, use of the staff, medications, supplies, and transportation to medical appointments if not rendered in-house. Different types of therapy are also included (occupational, speech, physical).


· You pay nothing for the first 20 days then a co-pay of up to $ 200.00 a day.


· If you stay longer than the 100-day limit, the total cost of care is yours.


3. Nursing Home Care / SNF external care

· Part A covers external professionals that must come to the nursing home or SNF when the in-house staff cannot perform specialized services or is not licensed to do so: infusions or some injections, wound care, some therapies, etc.


· Cost should be included in the facility bill


· A Dr must certify that a patient has likely less than 6 months to live due to a terminal illness.


· Whether at home or in a nursing home, hospice care only provides palliative or comfort measure. Hospice care cannot include any treatment except in rare occasions when a new condition develops. For example, a dying cancer patient breaks a bone and needs an emergency intervention.


· There is no cost to patients for hospice care.


· These only apply to patients who cannot leave their home to get medical care due to their physical limitations or conditions (Not because of lack of a car

medicare part a: basics
medicare part a: basics

or convenience for example)


· The care needed must be temporary, and usually covers nursing services (infusions, injections, wound care), different types of therapy, and some medical supplies.


· There must be documented evidence of continued improvement of a medical condition, or at least maintained stability so that coverage can be approved by a physician at regular intervals.


· Cost is $ 0.00 although some independent providers might bill part B.


C. As in everything in healthcare, there are limitations.


1. Inpatient hospital services:

· All “professional” providers must bill part B. These are physicians and clinicians who may work at a facility, or treat you there, but who are not its employees. Ex: anesthesiologists, pathologists, surgeons, hospitalists, radiologists etc


· Their payment, and your share of cost, will be based on a different payment format.


· Whereas there is no lifetime limit on the number of benefit periods, mental health inpatient care is limited to 190 days per lifetime.


· Private nursing services, and other items deemed “personal” of for “comfort” are not covered by Medicare (massage therapy, private room, grooming items etc)


2. For SNF days to be covered:

· you must have been "inpatient" for at least 3 nights in a hospital.


· This does not necessarily mean you stayed there while you were under "observation" while the Dr determined whether you could be discharged or had to stay longer.


. Observation days are payable under part B, as “outpatient”. I know it makes little sense, but you must have been declared “inpatient” for at least 3 nights to qualify for SNF care.


3. Nursing home care:

· must be medically necessary, and NOT “custodial”.


· Care that can be performed by the patient or a non-licensed person is NOT payable by Medicare. This means someone helping with food prep, bathing, companionship, supervision, household chores or other basic non-skilled medical care such as giving oral medications or applying a band-aid.


· If the level of care drops, either because the patient no longer needs the service, or continued medical benefit cannot be justified, coverage will stop.


4. Hospice care:

· Cannot cover attempts at addressing, reversing or treating a terminal condition.


5. Home health services:

· must be medically justified on a regular basis, and (re)ordered by a physician.


D. Useful Tips


· Coverage and payments only apply to Medicare providers. Always confirm the status of a provider before hiring their services. Or visit: https://www.medicare.gov/care-compare/


· If a provider thinks or knows a service may be denied or not covered by Medicare, they must give you a ABN (”Advanced Beneficiary Notice”) form to review and sign. The form will list what item or service is in question, and the cost. You will be asked whether to go ahead.


· Medicare.gov is a treasure of info, simple and clearly searchable. The tab “what Medicare covers” is especially easy to use to find coverage and pricing data. Comparing supplemental plans in your area, what they cover and at what price is also easy to do on the website.




Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.


(424) 999 4705 - F (424) 226 1330

@martine brousse 2023

@ the medical bill whisperer 2023

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