Original Medicare: Getting Care in a Hospital, Nursing Home, at Home and with Hospice

The Original Medicare Plan has two parts:

• Hospital Insurance, called Part A, helps pay for hospital bills, and
• Medical Insurance, called Part B, helps pay for doctor bills.

Under the Original Medicare Plan, you choose your own doctors, specialists, and hospitals. Doctors and hospitals charge you for the care they give you. The Original Medicare Plan pays its share of the cost of your doctor and hospital bills and you pay your share.

Many people in the Original Medicare Plan have additional insurance, such as retiree health insurance or a Medicare Supplemental (Medigap) Insurance policy to pay for care Medicare doesn't cover.

Medicare Part A

Most people do not have to pay a monthly fee or premium for Part A. That is because they or their spouse paid Medicare taxes while they were working.

Medicare Part A helps pay for the cost of:

• hospital stays
• short term nursing home stays, following a hospital stay
• home health care, following a hospital stay
• hospice care

Medicare Part A

Medicare Part A does not pay all of the costs of hospital, skilled nursing home, home, and hospice care. The following describes what your share of the costs will be.

Care in a Hospital

Medicare Part A helps pay for hospital stays, including stays in psychiatric hospitals. Here's how it works:

• Once you pay your deductible, ($840 in 2003), Medicare pays the rest of your hospital bill for a stay of up to 60 days in a benefit period. A benefit period begins the day you go to the hospital and ends when you have been out of the hospital for 60 days in a row.
  If you go into the hospital again before you've been out 60 days, you continue in the "old" benefit period. If you go into the hospital again after you have been out at least 60 days, you begin a new benefit period. You pay a deductible for each new benefit period.
• If you stay in the hospital more than 60 days, you will pay a bigger part of the bill.

How Much You and Medicare Pay for Hospital Care (In 2003)

* Days 91-150 (60 days) are called lifetime reserve days. They can be used after you have been in the hospital 90 days. You don't need to use these lifetime reserve days all at once. There are 190 lifetime day reserve days for stays in a psychiatric hospital.

In the hospital, Medicare Part A helps pay for:

• semi-private room and meals
• resident and intern services
• nursing services
• medical social services
• drugs, shots, and blood for use in the hospital
• equipment, such as wheelchairs, and medical supplies
• physical therapy
• planning for follow-up care

In the hospital, Medicare Part A does not pay for:

• private-duty nursing (you hire your own private nurse)
• private rooms (unless the doctor says you need a private room for your health)
• television
• telephone

Care in a Nursing Home

Medicare Part A helps pay for some of your stay in a nursing home. A skilled nursing facility is a place where you get skilled nursing or rehabilitative care from licensed health professionals. Help from family members or care you give yourself is not considered skilled nursing care.

You must meet these conditions for Medicare to help pay for your care in a nursing home:

• You need to have been in the hospital for three or more days before you go to a skilled nursing home. Your care must begin within 30 days after you leave the hospital.
• Your doctor must order daily skilled nursing or rehabilitation services that you can get only in a skilled nursing home. "Daily" means seven days a week for skilled nursing services and five days a week or more for skilled rehabilitation services.
• You get these skilled services in a nursing home that has been approved by Medicare.

If you meet these conditions, Medicare pays for up to 100 days in a benefit period. A benefit period begins the day you go into the hospital or skilled nursing home. The benefit period ends when you have been out of the hospital or skilled nursing home for at least 60 days in a row. You pay a deductible ($840 in 2003) for each new benefit period.

How Much You and Medicare Pay for Skilled Nursing Home Care (In 2003)

If you need care in a skilled nursing home at a later time, you must again meet the same conditions for Medicare to help pay for your care.

In a skilled nursing home, Medicare helps pays for:

• a semi-private room
• meals
• skilled nursing and rehabilitative services
• medical social services
• prescription drugs, medical supplies and equipment
• possible ambulance service
• dietary counseling
• other services such as lab tests and x-rays

Care at Home

Medicare Part A and Part B both help pay for home health care. Home health care is skilled nursing and other kinds of health care services that you get in your home to treat an illness or injury. (Medicare doesn't pay for care to help you with activities of daily living, such as bathing, dressing, eating or using the toilet.)

You must meet four conditions for Medicare to help pay for your home health care:

1. Your doctor must order medical care for you in your home and make a plan for that care.
2. You must need help from a skilled nurse or a physical, occupational, or speech therapist on a part-time basis. Medicare does not pay for these services round-the-clock (24 hours).
3. You must be homebound. This means it is very hard for you to leave your home because of your illness or injury.
4. You must get your care from a home health care agency that is approved by Medicare.

What Medicare Pays

Medicare will pay for your home care for as long as you meet these conditions. Your doctor and home health care agency will review your plan of care at least every 60 days.

Medicare will pay for the following as part of your home health care:

• part-time skilled nursing care
• home health aides
• physical, occupational, or speech therapists
• medical social services or counseling to help you cope with your illness or injury
• medical equipment and supplies

What You Pay

You do not have to pay anything for these services as long as you meet the four conditions listed above. However, you must pay 20 percent of the cost of medical equipment and 100 percent of the costs of outpatient prescription drugs.

Hospice Care

Medicare Part A will help pay for your hospice care. Hospice care is a special way of caring for people who are dying and for their family members. The focus of hospice care is to help make people as comfortable as possible at the end of their life rather than try to cure their illness or injury. While you can receive hospice care in your home, a hospice facility, a nursing home, or a hospital, most people use hospice care at home.

You must these conditions for Medicare to pay for your hospice care:

• You must have or be able to get Medicare Part A.
• A doctor must say you are terminally ill.
• You, or the person who is making your health care decisions, must sign and send a form to Medicare to tell them you are choosing hospice care.*
• You must get care from a hospice approved by Medicare.

*Once you choose hospice care, you can't use your Medicare benefits to cure your terminal illness. You can, however, get care for other health problems. If for any reason you stop hospice care, you will again get your health care from Medicare.

For example, Mary is getting hospice care for cancer. She is not using Medicare to continue chemotherapy or radiation to cure her illness. Unfortunately, while receiving hospice care, Mary fell and broke her wrist. Medicare will pay for treating her broken wrist.

What Medicare Pays

You get hospice care for up to two 90-day periods, followed by an unlimited number of 60 day periods. At the start of each period of care, your doctor must confirm that you still terminally ill in order to continue the care.

Medicare pays for the following services as part of your hospice care:

• doctor and nursing care
• drugs to help control your pain
• dietary counseling
• counseling for you and your family
• short-term hospital care (including respite care)
• physical, occupational, and speech therapy
• medical social services
• home health aide and homemaker services
• medical supplies and equipment

What You Pay

You pay up to $5 for each prescription drug. You also pay 5 percent of the Medicare-approved amount for respite care. Respite care is short-term care given to you so that your caregiver can get some rest, run errands or get away for a few days.

AARP Resources

Checklist: 20 Ways to Identify the Local Hospital That's Best for You
AARP reports on how to check on the quality of care in local hospitals.

State-by-State List of Nursing Home Performance Data
AARP provides information on how to find out about complaints or problems with nursing homes.

Checklist: What to Look for In a Nursing Home
Tips on what to look for in a good nursing home.

Choosing a Good Nursing Home
Getting started on finding a good nursing home.

End of Life Issues
AARP covers end of life issues such as "Dealing with Pain" and "At the End of Life."

Understanding Medicare, Medigap, and Medicaid
AARP explains how these programs work.

Additional Resources

State Health Insurance Assistance Program (SHIP)
How to contact your State Health Insurance Assistance Program (SHIP), an important Medicare partner. Free one-on-one health insurance counseling to people with Medicare.

National Association of Home Care
Information about Medicare coverage for home health care.

Hospice Association of America (HAA)
Consumer's guide to hospice care

National Hospice Foundation
Information about hospice care and the Medicare hospice benefit