MEDICARE HOSPITAL INSURANCE BENEFITS (PART A)

MEDICARE HOSPITAL INSURANCE BENEFITS (PART A)


When all program requirements are met, Medicare Part A
helps pay for medically necessary inpatient care in a hospital,
skilled nursing facility or psychiatric hospital, and for
hospice care. In addition, Part A pays the full cost of
medically necessary home health care and 80 percent of the
approved cost for wheelchairs, hospital beds, and other durable
medical equipment (DME) supplied under the home health care
benefit.


Benefit Periods


Medicare Part A hospital and skilled nursing facility
benefits are paid on the basis of benefit periods. A benefit
period begins the first day you receive a Medicare-covered
service in a qualified hospital. It ends when you have been out
of a hospital or skilled nursing or rehabilitation facility for
60 days in a row. It also ends if you remain in a skilled
nursing facility but do not receive any skilled care there for
60 days in a row.

If you enter a hospital again after 60 days, a new benefit
period begins. With each new benefit period, all Part A
hospital and skilled nursing facility benefits are renewed
except for any lifetime reserve days or psychiatric hospital
benefits that were used. There is no limit to the number of
benefit periods you can have for hospital or skilled nursing
facility care.


Inpatient Hospital Care


If you are hospitalized, Medicare will pay all charges for
covered hospital services during the first 60 days of a benefit
period except for the deductible. The Pan A deductible in 1994
is $696 per benefit period. You are responsible for the
deductible. In addition to the deductible, you are responsible
for a share of the daily costs if your hospital stay lasts more
than 60 days. For the 61st through the 90th day, Part A pays
for all covered services except for coinsurance of $174 a day
in 1994. You are responsible for the coinsurance.

Under Part A, you also have a lifetime reserve of 60 days
for inpatient hospital care. These lifetime reserve days may be
used whenever you are in the hospital for more than 90
consecutive days. When a reserve day is used, Part A pays for
all covered services except for coinsurance of $348 a day in
1994. Again, the coinsurance is your responsibility. Once used,
reserve days are not renewed.


Gaps in Medicare Inpatient Hospital Coverage:


* You pay $696 deductible on first admission to hospital in
each benefit period.

* You pay $174 daily coinsurance for days 61 through 90.

* No coverage beyond 90 days in any benefit period unless
you have "lifetime reserve" days available and use them.

* You pay $348 daily coinsurance for each lifetime reserve
day used.

* No coverage for the first 3 pints of whole blood or units
of packed cells used in each year in connection with
covered services. To the extent the 3-pint blood
deductible is met under Part B, it does not have to be met
under Part A.

* No coverage for a private hospital room, unless medically
necessary, or for a private duty nurse.

* No coverage for personal convenience items, such as a
telephone or television in a hospital room.

* No coverage for care that is not medically necessary or
for non-emergency care in a hospital not certified by
Medicare.

* No coverage for care received outside the U. S. and its
territories, except under limited circumstances in Canada
and Mexico.


Skilled Nursing Facility Care


A skilled nursing facility (SNF) is a special kind of
facility that primarily furnishes skilled nursing and
rehabilitation services. It may be a separate facility or a
distinct part of another facility, such as a hospital. Medicare
benefits are payable only if you require daily skilled care
which, as a practical matter, can only be provided in a skilled
nursing facility on an inpatient basis, and the care is
provided in a facility certified by Medicare. Medicare will not
pay for your stay if the services you receive are primarily
personal care or custodial services, such as assistance in
walking, getting in and out of bed, eating, dressing, bathing
and taking medicine.

To qualify for Medicare coverage for skilled nursing
facility care, you must have been in a hospital at least three
consecutive days (not counting the day of discharge) before
entering a skilled nursing facility. You must be admitted to
the facility for the same condition for which you were treated
in the hospital and the admission generally must be within 30
days of your discharge from the hospital. Your physician must
certify that you need, and receive, skilled nursing or skilled
rehabilitation services on a daily basis.

Medicare can help pay for up to 100 days of skilled care
in a skilled nursing facility during a benefit period. All
covered services for the first 20 days of care are fully paid
by Medicare. All covered services for the next 80 days are paid
by Medicare except for a daily coinsurance amount. The daily
coinsurance in 1994 is $87. You are responsible for the
coinsurance. If you require more than 100 days of care in a
benefit period, you are responsible for all charges beginning
with the 101st day.


Gaps in Medicare Skilled Nursing Facility, Coverage:


* You pay $87 daily coinsurance for days 21 through 100 in
each benefit period.

* No coverage beyond 100 days in a benefit period.

* No coverage for care in a nursing home, or in a SNF not
certified by Medicare, or for just custodial care in a
Medicare-certified SNF.

* No coverage for 3-pint blood deductible (see list of gaps
under inpatient hospital care).


Home Health Care


Medicare fully covers medically necessary home health
visits if you are homebound, including parttime or intermittent
skilled nursing services. A Medicare-certified home health
agency can also furnish the services of physical and speech
therapists. Should you require speech-language pathology,
physical therapy, continuing occupational therapy or
intermittent skilled nursing services, are confined to your
home, and are under the care of a physician, Medicare can also
pay for medical supplies, necessary part-time or intermittent
home health aide services, occupational therapy, and medical
social services. Coverage is also provided for a portion of the
cost of wheelchairs, hospital beds and other durable medical
equipment (DME) provided under a plan-of-care set up and
periodically reviewed by a physician.


Gaps in Medicare Home Health Coverage


* No coverage for full-time nursing care.

* No coverage for drugs or for meals delivered to your home

* You pay 20% of the Medicare-approved amount for durable
medical equipment, plus charges in excess of the approved
amount on unassigned claims.

* No coverage for homemaker services that are primarily to
assist you in meeting personal care or housekeeping needs.


Hospice Care


Medicare beneficiaries certified as terminally ill may
choose to receive hospice care rather than regular Medicare
benefits for their terminal illness. Part A can pay for two
90-day hospice benefit periods, a subsequent period of 30 days,
and a subsequent extension of unlimited duration. If you enroll
in a Medicare-certified hospice program, you will receive
medical and support services necessary for symptom management
and pain relief. When these services which are most often
provided in your home-are furnished by a Medicare-certified
hospice program, the coverage includes: physician services,
nursing care, medical appliances and supplies (including drugs
for symptom management and pain relief), short-term inpatient
care, counseling, therapies, home health aide and homemaker
services.

You do not have to pay Medicare's deductibles and
coinsurance for services and supplies furnished under the
hospice benefit. You must pay only limited charges for
outpatient drugs and inpatient respite care. In the event you
require medical services for a condition unrelated to the
terminal illness, regular Medicare benefits are available. When
regular benefits are used, you are responsible for the
applicable Medicare deductible and coinsurance amounts.


Gaps in Medicare Hospice Coverage:


* You pay limited charges for inpatient respite care and
outpatient drugs.

* You pay deductibles and coinsurance amounts when regular
Medicare benefits are used for treatment of a condition
other than the terminal illness.


Psychiatric Hospital Care


Part A helps pay for up to 190 days of inpatient care in a
Medicare-participating psychiatric hospital in your lifetime.
Once you have used 190 days (or have used fewer than 190 days
but have exhausted your inpatient hospital coverage), Part A
doesn't pay for any more inpatient care in a psychiatric
hospital. However, psychiatric care in general hospitals,
rather than in free-standing psychiatric hospitals, is not
subject to this 190-day limit. Inpatient psychiatric care in a
general hospital is treated the same as other Medicare
inpatient hospital care. If you are a patient in a psychiatric
hospital on the first day of your entitlement to Medicare,
there are additional limitations on the number of hospital days
that Medicare will pay for.


Gaps in Medicare Inpatient Psychiatric Hospital Care:


* No coverage for care after you have received 190 days of
such specialized treatment in your lifetime (even if you
have not yet exhausted your inpatient hospital coverage).