Most individuals automatically get Medicare Part A coverage based on the work history of the individual or the individual’s spouse. However, individuals who do not automatically get Part A coverage may still be eligible for Part A and get the premium paid by the Department of Human Services through the Medicare Buy-In Program. Eligible individuals include SSI recipients and other Qualified Medicare Beneficiaries (QMBs). See Chapter 388.2, Buy-In of Medicare Part A, for eligibility requirements and Chapter 388.6, Authorizing Buy-In, for the manual enrollment process.
Important: If the individual already has Medicare Part B, the individual can be enrolled in the Medicare Part A Buy-In through a CAO manual accrete process. The individual does not have to go to the Social Security Administration office to apply for Medicare Part A. The individual should be referred to the Social Security Administration to apply for Medicare only if the individual does not have Medicare Part B coverage.
Medicare Part A covers:
Hospitals stays
Inpatient care in hospitals, including semi-private rooms, meals, nursing services, supplies, and other services ordinarily provided by the hospital. Inpatient hospital care is limited to 90 days for each benefit period. An additional 60 days are available as non-reusable lifetime reserve days.
Mental health care in a psychiatric hospital is limited to 190 days in a lifetime.
Blood
Beginning with the fourth unit of blood received at a hospital or Long Term Care (LTC) facility during a covered stay.
Hospice Care
Hospice care for individuals with a terminal illness and a life expectancy of six months or less. Hospice coverage is available for two 90-day periods, followed by an unlimited number of 60-day periods.
Important: Hospice care can continue even if the individual lives for more than six months.
Hospice care includes physician and nursing services, grief counseling, medical social services, physical, occupational, and speech therapy, medical supplies and appliances, home health aide and homemaker services, outpatient drugs for symptom management and pain relief, and respite care.
Home Health Services
Part-time and intermittent skilled care for physical therapy, occupational therapy or speech-related pathology and medical social services. Durable medical equipment like wheel chairs, hospital beds, oxygen and walkers may also be covered.
Skilled Care/LTC
Stays in skilled nursing facilities (but not LTC or custodial care) which includes semi-private rooms, meals, skilled nursing and rehab services up to 100 days in a benefit period only after a three day inpatient hospital stay. A benefit period begins the day you go in to the hospital or Skilled Nursing Facility (SNF). The benefit period ends when you have not received any hospital or SNF care for 60 days in a row.
Inpatient care in a Religious Non-medical Health Care Institution (coverage is related to non-medical, non-religious parts of care).
Medicare beneficiaries have significant deductibles and co-pays for services covered under Part A unless the individual has secondary coverage (for example: Medical Assistance or a Medigap plan) to help pay those costs.
Example: 2016 Rates
Hospital Stay - $1,288 deductible
LTC Facility Care - $0 for first 20 days
Skilled Care - $161.00/day for days 21 – 100 days
NOTE: For the first 20 days Medicare will make full payment for LTC facility services.
2015 rates:
Hospital Stay - $1,260.00
LTC Facility Care - $0 for the first 20 days
Skilled Care - $157.50/day for days 21 - 100 days
NOTE: For the first 20 days Medicare will make full payment for LTC facility service
After $1,288 deductible:
100% Medicare coverage for 1 – 60 days of a hospital stay
$322.00 per day for 61 – 90 days of a hospital stay
$644.00 per day for hospital stays beyond the 90th day
Benefit Period for Part A: 2015
After $1,260.00 deductible
100% Medicare coverage for 1 - 60 days of a hospital stay
$ 315.00 per day for 61 - 90 days of a hospital stay
$630.00 per day for hospital stays beyond the 90th day
Most individuals do not pay a premium for Medicare Part A, because the individual or the spouse of the individual or a parent in the case of a disabled adult child has paid Medicare taxes through their employment for more than 40 quarters. Individuals age 65 or older with 39 quarters or less and disabled individuals who have lost free Part A because of a return to work or a parent’s return to work in the case of a disabled adult child, may also be eligible to buy Part A coverage.
Medical Assistance can purchase Part A coverage for certain individuals aged 65 or older who are eligible for Part A but who would have to pay for it (for example, those over 65 who receive SSI benefits. See Section 387.5)
Individuals have to meet an annual Part A deductible before Medicare starts covering 80% of the costs. The 2015 annual deductible is $1,184
The 2015 Part A premiums are as follows:
$441 per month for Medicare Part A
$248 per month for individuals who have 30 – 39 work quarters
Monthly premium set according to a statutory formula for individuals with fewer than 30 work quarters
The enrollment period for Part A is January through March to be effective July 1st of the same year.
Updated April 4, 2016 Replacing December 15, 2014