Medicare Coverage of Hospital Inpatient Care
What It Is
Hospital inpatient care
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
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.
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