What Medicare covers in the hospital - Ahwatukee Foothills News: Opinion

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What Medicare covers in the hospital

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David Sayen is Medicare’s regional administrator for Arizona, California, Nevada, Hawaii and the Pacific Trust Territories.

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Posted: Thursday, December 29, 2011 2:00 pm

One of Medicare's most important benefits is helping to cover your expenses if you need to be hospitalized. But what exactly is covered, and how much do you pay?

Medicare helps cover certain medical services and supplies in hospitals. To get the full range of benefits, you must have both Medicare Part A, which is hospital insurance, and Part B, which is medical insurance.

What you pay depends on whether you're an in-patient or an out-patient. Staying overnight in a hospital doesn't always mean you're an in-patient. You're an in-patient on the day the doctor formally admits you, with a doctor's order.

If you aren't sure whether you're an in-patient or an out-patient, ask your doctor or the hospital staff. Or you can call Medicare at 1-800-MEDICARE (1-800-633-4227).

If you're admitted as an in-patient, Part A will help cover your stay. This would generally include a semi-private room, meals, general nursing care, drugs, and other hospital services and supplies.

How much you'll pay depends partly on how long you stay.

Medicare pays for in-patient hospital care and skilled nursing care based on "benefit periods." A benefit period begins the day you're admitted to a hospital or skilled nursing facility - and ends when you haven't had any care in either setting for 60 days in a row.

You can have more than one hospital stay within the same benefit period. There's a limit on how many days Medicare covers during a benefit period, but there's no limit on the number of benefit periods you can have over your lifetime.

So much actually comes out of your pocket when you're in the hospital?

Part A has a deductible, which is $1,156 for 2012.

After you've paid that, there's no co-payment for days one through 60 of each benefit period. For days 61 through 90 of each benefit period, there's a co-payment of $289 per day next year.

You also have 60 "lifetime reserve days." These can be used after day 90 of each benefit period, and your co-pay is $578 per day in 2012. After you use up these "lifetime reserve days," you must pay all costs yourself.

If that all seems a bit complicated, you can always call us with your questions at 1-800-MEDICARE.

You can also find a lot of good information in the "Medicare & You" handbook, which is mailed to all Medicare beneficiaries in the country each fall. The handbook is online at www.Medicare.gov.

Keep in mind that Part A doesn't cover doctor fees or other medical services. That's where Part B comes in.

To get Part B, you must pay a monthly premium, which for most people will be $99.90 per month in 2012.

Then you'll pay 20 percent of the Medicare-approved amount for most doctor services while you're an inpatient. Part B also helps cover outpatient costs, such as doctors' fees, emergency and observation services, lab tests, and X-rays.

I should also point out some of things Medicare doesn't cover in the hospital.

It doesn't pay for private-duty nursing, a telephone or television, personal items (like toothpaste or razors), or a private room, unless it's medically necessary.

For hospital outpatient care, you pay a co-payment for each individual out-patient service.

The co-payment can be different for each service, but never more than the Part A deductible. In some cases, your total co-payment for all services may be more than the in-patient hospital deductible.

• David Sayen is Medicare's regional administrator for Arizona, California, Nevada, Hawaii, and the Pacific Trust Territories. Get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

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