Medicare Part A – General Coverage Information
Medicare Part A is “Hospital Insurance” that helps cover inpatient care in hospitals, skilled nursing facility, hospice, and home health care. Since this is the Medicare coverage most people get premium free when they turn 65 years of age, let’s delve a little deeper into these benefits.
Inpatient care in hospitals includes critical access hospitals, inpatient rehabilitation facilities, and long-term hospitals. (It is important to note that staying overnight in a hospital does not always qualify as an “inpatient” event. Your physician must formally order your admission you to a hospital. )
Inpatient care in a skilled nursing facility does not include custodial care, or long-term care. (Long term, custodial care usually refers to assistance with activities of daily living like dressing, bathing, and using the bathroom.)
Home health care includes services and supplies a physician orders for you that you will receive in your home. These services and supplies must fall under a plan of care established by your doctor, and are usually only covered on a limited basis as ordered by your doctor.
Hospice is covered by Part A even if a beneficiary is enrolled in a Medicare Advantage Plan. Hospice care is intended for terminally ill patients and involves a team-oriented approach to “addresses the medical, physical, social, emotional, and spiritual needs of the patient,” while also supporting the patient’s family or caregivers.
You are likely eligible for Medicare Part A when you reach 65 years of age and fall into one of the following categories:
- You already receive benefits from Social Security or the Railroad Retirement Board.
- You are eligible for Social Security, but have not signed up yet.
- You or your spouse had Medicare-covered government employment.
Many people are eligible for Part A before they turn 65. For instance, if you have been receiving Social Security or Railroad Retirement Board disability benefits for 24 months, or if you have ESRD (end-stage renal disease) and meet certain requirements, you will likely be eligible for Part A.
Part A is usually premium-free to most people who have paid Medicare taxes while working. If you are not eligible for premium-free Part A, you may be able to purchase Part A under the following circumstances:
- If you are 65 years of age or older, are enrolling in Part B, and you meet the citizenship or residency requirements. You will have to pay monthly premiums for both Part A and Part B.
- If you are under 65, disabled, and your premium-free Part A coverage ended because you returned to work. (If you are under 65 and disabled, you can continue to get premium-free Part A for up to 8.5 years after you return to work.)
When you are eligible for Part A, you are also eligible for Part B, also known as medical insurance. If you do not sign up for Part B when you are initially enrolled, you may have to pay a late enrollment penalty.
If you are eligible for Medicare Part A, you may not even have to sign up! You may be automatically enrolled under certain circumstances, including the following:
• You are already getting benefits from Social Security or the Railroad Retirement Board.
• You are under 65 and have certain disabilities.
• You have ALS (also known as Lou Gehrig’s Disease)
• You live in Puerto Rico and already receive Social Security or Railroad Retirement Board benefits.
If you fall into one of those categories, you will simply receive your Medicare card in the mail three months prior to your 65th birthday, or during your 25th month of disability. Please note: If you do not want Medicare Part B, you will need to follow the instructions on your red, white and blue Medicare card and send the card back. If you keep the card, you are keeping Part B and will be paying a monthly premium for the Part B benefits.
When you turn 65, you have a 7-month initial enrollment period during which you can sign up for Part A and/or Part B. This period begins three months before you turn 65, includes the month you turn 65, and ends three months after you turn 65.
If you did not sign up for Medicare during your initial enrollment period, you have a General Enrollment Period between January 1 and March 31 each year. Your coverage would begin on July 1 of that year. Keep in mind that you may have to pay a late enrollment fee if you did not sign up for Part b when you were originally eligible. This penalty can affect your monthly expenses for your duration on Medicare, so it is important to consider all of your options when you first reach eligibility.
Enrolling in a Medicare Advantage Plan
Medicare beneficiaries can get their benefits through Original Medicare or through a Medicare Advantage Plan, run by a private insurance company that contracts with Medicare to provide your benefits. You will need to enroll in both Part A and Part B. Medicare Advantage Plans must provide at least the same benefits as Original Medicare, with many offering additional benefits, such as vision care, dental care, hearing exams, prescription drug coverage, and more.
You have choices with Medicare Advantage (also known as Medicare Part C). There are many plans to choose from. Comparing the ones available in your area is the best way to find the one that is right for you. Your personal circumstances, budgetary goals, and medical needs are factors in your decision-making process, and with a little research, you can find coverage that will meet your individual needs and preferences. On-line comparison tools make the process easier than ever before, by giving you the opportunity to compare plans side by side, and request plan information based on specific criteria, such as the maximum premium/deductibles/copayments you are comfortable with, and the prescription drugs you need covered by the plan’s formulary (list of covered drugs).
Special Enrollment Periods
There are also Special Enrollment Periods (also known as SEPs) during which you may enroll in Part A and/or Part B without penalty, if you qualify. For example, if you were serving as a volunteer in a foreign country, you may be eligible for a Special Enrollment Period. You may be eligible to make changes to your Medicare Advantage or Medicare prescription drug coverage when certain events happen in your life, like if you move or you lose other insurance coverage.