Medicare Coverage of Hospital Inpatient Care

What It Is

Hospital inpatient care

What's Covered

Medicare Part A covers a medically necessary inpatient hospital stay, plus all care provided to the patient by hospital staff and facilities related to that stay. Coverage includes:

• Semi-private room (private room if medically necessary)

• Special care units (such as intensive care and coronary care)

• Operating room charges

• Nursing services

• Drugs, supplies, and appliances provided by the hospital

• Special treatments (such as chemotherapy and dialysis)

• Lab and diagnostic tests (such as X-rays and CAT scans)

• Rehabilitation (physical, speech, and occupational therapy)

Medicare Part A doesn't cover care in the hospital by a doctor (such as a surgeon, radiologist, anesthesiologist, oncologist, or other treating physician) who isn't on the hospital staff; those services are covered instead by Medicare Part B.

Medicare Part A coverage is for care in U.S. hospitals only, including Puerto Rico, the U.S. Virgin Islands, Guam, and American Samoa. It doesn't cover even emergency hospital care outside the U.S.

If a patient could receive the same care as an outpatient, Medicare Part A won't cover inpatient care. Likewise, there's no Medicare Part A coverage for a hospital stay related to elective surgery or other treatment that's not medically necessary. Also, even if Medicare Part A covers a hospital stay, coverage will end if a patient remains in the hospital after the doctors and hospital have declared the patient ready for discharge.

If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for hospital inpatient care, contact the plan directly.

What Medicare Pays

Medicare Part A payments are calculated for each "benefit period." This is the time period during which someone is a hospital inpatient, plus the following time in a Medicare-covered skilled nursing or rehabilitation facility. The benefit period begins the first day in the hospital and continues until the patient has been out of the hospital and other Medicare-covered facility for 60 consecutive days.

In any benefit period, Medicare Part A pays 100 percent of covered care for the first 60 days in the hospital, except for a hospital inpatient deductible of $1,132 (in 2011). If a hospitalization lasts more than 60 days in any one benefit period, Medicare Part A pays all covered costs except a patient coinsurance amount of $283 (in 2011) per day for days 61 to 90.

If a hospitalization lasts more than 90 days, Medicare Part A pays the full amount for covered care except for a patient coinsurance amount of $566 (in 2011) a day, up to 150 days. After 150 days in any one benefit period, Medicare Part A pays nothing for hospital care. These days 91 to 150 are known as "reserve days." There are only 60 reserve days in a lifetime. Once they're used up, a patient is responsible for the full cost of all hospital days beyond 90 days in any benefit period.

Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:

• The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?

• The care must be performed or delivered by a healthcare provider who participates in Medicare.