There is no way to sugarcoat it. A hospital inpatient stay can be very expensive. When enrolling in Medicare for the first time or switching coverage, one of the first questions you might have is “will Medicare cover my hospital stay?”
Yes! Medicare provides coverage for the majority of hospital inpatient services. However, they will not cover you indefinitely. Keep reading for a complete understanding of Medicare’s coverage of hospitalization.
- Medicare Part A covers most health care services while you are hospitalized.
- Medicare will not cover any inpatient care services that are not part of your medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. treatment, such as luxury items.
- Medicare coverage begins once you have paid the deductible for your benefit periodA benefit period is a method used in Original Medicare to measure a beneficiaries use of hospital and skilled nursing facility (SNF) services. With each new benefit period, the beneficiary is charged a new benefit... during your hospital stay.
- Once you have been discharged from the hospital and have not returned for a 60-day period, your benefit period ends.
- Outpatient hospital services, which do not require a hospital stay, are covered by Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services..
- MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. plans help with out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. for hospital services covered by Medicare, as well as allow you to use extra lifetime reserve daysMedicare Part A covers up to 90 days of inpatient care per benefit period. Beneficiaries get an additional 60 days of coverage known as lifetime reserve days. Lifetime reserve days can be used once. Beneficiaries....
- Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). will cover the same hospital services as Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Part B, but the out-of-pocket costs can vary wildly.
How Does Medicare Cover a Hospital Stay?
Medicare Part A covers doctor-ordered inpatient services during a hospital stay. This includes a wide range of medically necessary services to help with your treatment, including:1Medicare.gov, “Inpatient Hospital Care”, Accessed December 29, 2021
- Semi-private room
- Nursing services
- Diagnostic services
- Therapeutic services
- Medically necessary surgeries
- Medical supplies (IV poles, bandages, etc.)
- Durable medical equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds. (crutches, wheelchairs, etc.)
What Hospital Services are Not Covered By Medicare?
There are certain hospital services and supplies that are not covered by Medicare. This is because it is not medically necessary for you to have these services to get better:1Medicare.gov, “Inpatient Hospital Care”, Accessed December 29, 2021
- Private nurses
- Private rooms (unless it is necessary for treatment)
- Televisions and phones
- Personal care items (razors, slipper socks, etc.)
How Long Will Medicare Cover My Hospital Stay?
Your Medicare Part A benefit period begins once you are admitted to the hospital by your doctor. Your Part A deductible, currently $1,600, must be paid every new benefit period before Medicare provides coverage for services. Once you have paid your deductible, you pay:1Medicare.gov, “Inpatient Hospital Care”, Accessed December 29, 2021
- Days 1–60: $0 coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. for each benefit period.
- Days 61–90: $400 coinsurance per day of each benefit period.
- Days 91 and beyond: $800 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime).
- Beyond lifetime reserve days: All costs.
Once you are discharged from the hospital and if you do not return for at least 60 consecutive days, that benefit period ends. If you return to the hospital within 60 days after being discharged, your current benefit period will continue.2Medicare.gov, “Glossary: B”, Accessed December 29, 2021
How Does Medicare Cover Outpatient Hospital Services?
Hospitals do not only provide inpatient services. Hospitals also have outpatient departments that handle services for patients that have not been admitted as an inpatient. Examples of hospital outpatient services include:3Medicare.gov, “Outpatient Hospital Services”, Accessed December 29, 2021
- Emergency rooms
- Observation services
- Outpatient surgeries
- Laboratory tests and screenings
- Outpatient drugs (require administration by a doctor)
- Medical supplies
- Preventive care services
- Partial hospitalization for mental health care
- Chemotherapy4Medicare.gov, “Chemotherapy”, Accessed December 29, 2021
- Durable medical equipment (DMEs)5Medicare.gov, “Durable Medical Equipment (DME) coverage”, Accessed December 29, 2021
- Blood transfusions6Medicare.gov, “Blood”, Accessed December 29, 2021
- Physical therapy7Medicare.gov, “Physical Therapy”, Accessed December 29, 2021
Medicare Part A does not cover hospital outpatient services, including emergency room services. Instead, Medicare Part B provides coverage for these services.3Medicare.gov, “Outpatient Hospital Services”, Accessed December 29, 2021 If you are admitted to the hospital and you require these services for your hospital’s outpatient department, your Part B would cover them once you have paid your Part B annual deductible ($226).
Medigap policies, also known as Medicare supplemental insurance, help with out-of-pocket costs after Medicare Part A and/or Part B has provided coverage for the service. However, the type of out-of-pocket cost that a Medigap plan will help with varies between plans and can include:8Medicare.gov, “How to compare Medigap policies”, Accessed December 29, 2021
- DeductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.
- CopaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.
- Blood (first 3 pints), if needed for your treatment
In addition to helping with out-of-pocket costs, all current Medigap plans allow their beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. an extra 365 lifetime reserve days while they hold the plan. If you decide to leave a Medigap plan, you do not get to keep and use any remaining lifetime reserve days.8Medicare.gov, “How to compare Medigap policies”, Accessed December 29, 2021
Medicare Advantage plans are private insurances that must provide the same service coverage that Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. (Part A and Part B). However, that is where a lot of the similarities end, especially for hospital stays. This is because the out-of-pocket costs for covered services can vary wildly from plan to plan compared to Original Medicare.9Medicare.gov, “How do Medicare Advantage Plans work?”, Accessed December 29, 2021
For example, a study from the Kaiser Family Foundation indicates that 98 percent of Medicare Advantage plan members pay less out-of-pocket for the first three days in the hospital. This figure drops dramatically by the fifth day of hospitalization, with 50 percent of Medicare Advantage plan members paying more out-of-pocket than Original Medicare beneficiaries. By the seventh day, about 64 percent of Medicare Advantage plan members pay more out-of-pocket. By day ten, it is 72 percent of Medicare Advantage plan members.10KFF.org, “A Dozen Facts About Medicare Advantage in 2020”, Accessed December 29, 2021
While this study does not include MA Special Needs Plans, it also does not factor in Medigap plans. Medigap plans can help with remaining out-of-pocket costs for Original Medicare beneficiaries, but they are completely unavailable for any MA plan members11Medicare.gov, “Medigap & Medicare Advantage Plans”, Accessed December 29, 2021. This can give Original Medicare beneficiaries an advantage over Medicare Advantage plan members when it comes to the bill after a hospital stay.
Hospitals are really expensive, but Medicare will help you reduce your remaining costs for most medical services that hospitals provide. The best way to get ahead of your hospital bills is to understand how Medicare Part A and Part B provide coverage for hospital services. You should also consider purchasing a Medigap plan, as it will save you money over time for numerous medical expenses, including hospitalization.
If you are a Medicare Advantage plan member, contact your plan provider and have them explain the potential costs for hospital stays over time. That way, if you have an emergency hospital stay, you will not be surprised by the final bill.
- 1Medicare.gov, “Inpatient Hospital Care”, Accessed December 29, 2021
- 2Medicare.gov, “Glossary: B”, Accessed December 29, 2021
- 3Medicare.gov, “Outpatient Hospital Services”, Accessed December 29, 2021
- 4Medicare.gov, “Chemotherapy”, Accessed December 29, 2021
- 5Medicare.gov, “Durable Medical Equipment (DME) coverage”, Accessed December 29, 2021
- 6Medicare.gov, “Blood”, Accessed December 29, 2021
- 7Medicare.gov, “Physical Therapy”, Accessed December 29, 2021
- 8Medicare.gov, “How to compare Medigap policies”, Accessed December 29, 2021
- 9Medicare.gov, “How do Medicare Advantage Plans work?”, Accessed December 29, 2021
- 10KFF.org, “A Dozen Facts About Medicare Advantage in 2020”, Accessed December 29, 2021
- 11Medicare.gov, “Medigap & Medicare Advantage Plans”, Accessed December 29, 2021