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Medicare Part A

Authored By: North Mississippi Rural Legal Services LSC Funded

Information

Medicare Part A

Hospital Benefits 2003

  1. What is the hospital benefit for Medicare Part A in 2003?
  2. What is a "spell of illness"?

Nursing Home

  1. What is the 2003 coverage for nursing home care under Medicare?

Hospice

  1. What is the 2003 coverage for hospice benefit under Medicare?

Medicare Home Benefit Part A

  1. What are the requirements for home health care under Medicare Part A?

Hospital Benefits 2003

What is the hospital benefit for Medicare Part A in 2003?

The deductible amount for 2003 is $840.00.

For days 1-60 in the hospital: After the deductible is paid, Medicare pays 100% for covered charges per "spell of illness".

For days 61-90 in the hospital: The patient pays to $210/day co-insurance (2003). Medicare pays 100% of remaining covered charges, per "spell of illness".

There are an additional non-renewable 60 "lifetime reserve days" that are covered by Medicare and may be used after the 90 days of coverage have been exhausted. However, Medicare coverage for the lifetime reserve days applies only to covered charges remaining after the patient's $420/day in co-insurance (2003).

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What is a "spell of illness"?

A "spell of illness" begins when an individual enters a hospital or post-hospital skilled nursing home and ends after the patient has been discharged from the institution for sixty consecutive days or remained in the institution, but has not received skilled nursing care for sixty consecutive days. If an individual enters a hospital or nursing facility after the end of a spell of illness, the benefits, deductibles and co-payments again apply.

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Nursing Home

What is the 2003 coverage for nursing home care under Medicare?

Medicare pays for a limited amount of nursing home care under the following circumstances. The beneficiary enters a Medicare certified nursing home within 30 days after release from an acute care hospital stay of at least three days. The physician orders skilled nursing or rehabilitation services for the same condition for which the beneficiary was receiving hospital care (or for a condition which arose in the nursing home while the beneficiary was being treated for the condition for which the beneficiary was receiving hospital care).

Medicare pays 100% of approved charges for days 1 - 20 in a Medicare certified nursing home.

The patient pays $105.00/day co-insurance for days 21 - 100 (2003). Medicare covers approved charges in excess of the co-insurance amount for days 21-100.

After day 100, Medicare pays nothing for nursing home care per spell of illness. Note: about ½ of all nursing home charges in the U. S. are paid for by Medicaid.

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Hospice

What is the 2003 coverage for hospice benefit under Medicare?

Hospice care is also provided under Part A of Medicare. Hospice care is designed for persons who are terminally ill, with the goal of making the patient and family comfortable rather than providing cure-oriented treatment. Hospice care can be provided for two 90 day periods and an unlimited number of 60 day periods. The hospice is reimbursed for all services on a cost based prospective payment basis which is capped at an annual amount. The beneficiary must be certified by his physician and the hospice medical director to be terminally ill (having a six month or less prognosis and have made a written election (which is revocable) to receive hospice care in lieu of other Medicare benefits. The recipient may pay five (5%) of the charge for prescription drugs up to $5.00 per prescription and five percent (5%) of the cost of respite care up to a maximum equal to the inpatient hospital deductible, $840 in 2003.

Hospice care includes skilled nursing care, physical therapy, occupational therapy and speech therapy; medical social services; home health aid and homemaker services; physicians' services (counseling services, including bereavement counseling, dietary counseling, and spiritual counseling); medical appliances and supplies, including drugs and biologicals; and short term inpatient care (including respite care) in an institutional setting.

To be covered, services must be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions and must be consistent with the plan of care.

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Medicare Home Benefit Part A

What are the requirements for home health care under Medicare Part A?

Home health benefits must be provided under a physician's plan of care and are provided through an arrangement with a licenced home health agency. To qualify, the beneficiary must be homebound. In other words, an individual must have an illness or injury that restricts the ability of the individual to leave his or her home except with the assistance of another individual, an assistive device, or that a considerable and taxing effort is required in order to leave the home.

Additionally, the service must be needed on an intermittent or part-time (rather than continuous) basis (less than 8 hours per day and 35 or fewer hours per week). The service provided must include skilled nursing care, physical, occupational or speech therapy services at least on a periodic basis. When the need for a skilled service has been established, the beneficiary can also received home health aide services on a more frequent basis to assist with hygiene and nutrition at home. Aide services include personal care assistance, as well as light housekeeping and meal preparation. Medical social services, medical equipment and supplies, and certain outpatient services arranged for by the home health agency are also included in the benefit.

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Last Review and Update: Nov 20, 2002