PART A: HOSPITAL INSURANCE
Posted by admin on October 13th, 2008
Part A of Medicare is supported by a payroll tax collected during a person’s working years. Part A represents paid-up hospital insurance for Medicare-qualified retirees, who pay no premiums during retirement. Generally, only people who are eligible to receive Social Security monthly payments are eligible for Medicare. Persons who never worked or who did not accumulate enough Social Security work quarters are not eligible for Medicare.
In general, a Medicare beneficiary is entitled to inpatient hospital care for a maximum number of days (60 days in 1993) during a benefit period. The beneficiary pays a deductible ($690 in 1994), which is established annually by the government. A benefit period begins when the person is admitted to the hospital and ends when the person has been out of the hospital or skilled nursing facility for a given number of consecutive days (60 days in 1993). A readmission in a new benefit period requires that another deductible be paid. If the patient’s hospival stay exceeds the maximum number of days in one benefit period, Medicare pays a large part of the recognized costs for days 61 to 90, and the beneficiary pays a daily copayment equal to one fourth of the deductible. This extension is limited to 30 hospital days. In addition, Medicare provides partial coverage for 60 hospital reserve days during a beneficiary’s lifetime; after these days are used, they cannot be replaced. The beneficiary pays one half of the deductible for reserve days. Part A provides some coverage for psychiatric hospital stays.
Medicare Part A covers virtually all hospital services, including discharge planning and medical social services. It covers the cost of a semiprivate room or, if medically necessary, a private room, but not such amenities as television and telephone.
The amount Medicare pays for hospitalization is predetermined by the diagnosis related group (DRG) that covers the beneficiary’s principal diagnosis. Some adjustment is made for age and comorbidity. The hospital may make or lose money, depending on how soon the patient is discharged and how many diagnostic and therapeutic services are used. Under this arrangement, the financial pressure for earlier discharge and <!– /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:”"; margin:0cm; margin-bottom:.0001pt; mso-pagination:none; mso-layout-grid-align:none; text-autospace:none; font-size:10.0pt; font-family:”Times New Roman”; mso-fareast-font-family:”Times New Roman”;} @page Section1 {size:612.0pt 792.0pt; margin:70.85pt 70.85pt 70.85pt 70.85pt; mso-header-margin:35.4pt; mso-footer-margin:35.4pt; mso-paper-source:0;} div.Section1 {page:Section1;} –>
limited intervention may conflict with medical judgment. When a patient cannot be discharged home safely or to a nursing home because no bed is available, Medicare pays a relatively low per diem for an alternate level of care.
Part A covers posthospital convalescent care and rehabilitative care in a nursing home. However, because Medicare does not pay for custodial or long-term care, coverage ends when the patient is stabilized and skilled professional care is no longer needed.
Hospice care is covered by Part A under certain conditions (see HOS-PICE CARE in Ch. 25). The beneficiary pays no deductible or copayment except for part of the costs of outpatient drugs and of respite care, a provision to support family members caring for the patient at home (see Respite Care in Ch. 25).
