Does Medicare Cover Hospital Stays?
Yes, Medicare covers hospital stays. As long as the hospital accepts Medicare and an inpatient stay fulfills an official doctor’s order, Medicare Part A (Hospital Insurance) pays your first 60 days after meeting your deductible. Residencies exceeding 60 days will require you to pay coinsurance, the rate of which can increase depending on the total length of your visit.
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Covering Inpatient Care When You Need It Most
Imagine you or a loved one must undergo some kind of treatment requiring extended time in the hospital. In 2021, the average cost for hospital admission across the US reached $2,883 per day. Luckily, Medicare would cover most of these expenses during your benefit period.
Medicare Part A covers the cost of inpatient stays at conventional hospitals, skilled nursing facilities, and non-custodial nursing homes, occasionally even extending coverage to include hospice care or home health care. Covered services can range from meals and medication to more extensive procedures like blood transfusions.
What Inpatient Services Does Medicare Cover?
Once admitted to a Medicare-approved hospital under doctor’s orders, services covered under Medicare Part A may include:
- A semiprivate room
- Medications (including methadone to treat opiate dependency)
- Meals
- Medical supplies
- Bloodwork and diagnostic testing
- Durable medical equipment like wheelchairs used onsite
- Nursing care
- Qualified surgeries
- Inpatient rehabilitation services
Medicare hospital coverage begins once you meet your Part A deductible and pays for the next 60 days of care. After 60 days, coinsurance fees apply. Inpatient doctor services, specialist procedures, and routine testing typically see coverage under Medicare Part B (Medical Insurance), which follows a separate billing structure.
Medicare Eligibility For Inpatient Coverage
To qualify for inpatient coverage, Medicare beneficiaries must obtain doctor’s orders explicitly stating they require inpatient hospital care to treat or monitor their condition. Patients must then seek out a hospital or inpatient facility that accepts Medicare.
Luckily, most doctors and hospitals nationwide agree to Medicare terms and billing procedures. In some special cases, Part A will even cover inpatient stays for unqualified candidates approved by their hospital’s utilization review committee.
Eligible Centers of Care
Medicare Part A hospitalization only utilizes services provided by eligible care centers. These institutions must exhibit minimum Medicare safety and expertise standards to perform complex medical procedures. Most medical facilities nationwide qualify as eligible care centers, including general acute and long-term care hospitals, skilled nursing facilities, rehabilitation centers, and psychiatric facilities.
General Acute Care Hospitals
Acute care hospitals aim to provide comprehensive — albeit short-term — inpatient medical care, treatment, or post-surgery monitoring. Typically, stays at general acute care hospitals do not exceed 25 days. You will likely end up in a GACH if you only need conventional surgery, routine diagnosis, or standard maintenance and monitoring on an acute injury or condition. Medicare Part A would fully cover your stay upon meeting your deductible.
Long-Term Acute Care Hospitals
Long-term acute care hospitals can exist as standalone facilities or function independently
within the walls of a general hospital. If you require ongoing ventilator use, severe wound or burn care, prolonged dialysis, or any other complex intensive care, you’ll likely get transferred from a GACH to an LTACH. After meeting your deductible, Medicare would fully cover the first 60 days of service and partially cover prolonged stays up to a specified limit.
Skilled Nursing Facilities
Skilled nursing facilities provide 24/7 professional nursing care for people who need daily medical attention but not to a degree requiring a hospital’s resources. Medicare-approved skilled nursing care includes medically necessary procedures like intravenous injections and physical therapy. However, custodial care like assistance bathing and eating does not qualify for Medicare coverage.
Rehabilitation Centers
Rehabilitation centers provide short-term care that helps patients rebuild cognitive and functional abilities following significant bodily trauma like a stroke or hip replacement surgery. Medicare would fully cover your first 60 inpatient days after meeting your deductible, as long as your doctor certifies you have a condition requiring intensive rehabilitation. Patients transferred to a rehab center from the hospital would not have to pay a second deductible, as this continued care would register under the same benefit period.
Inpatient Psychiatric Facilities
Inpatient psychiatric facilities treat individuals for mental health disorders like addiction, anxiety, and depression, as prescribed by a doctor. Medicare Part A will only cover 190 days of inpatient care in a psychiatric hospital over your lifetime. Alternatively, Medicare Part B would cover the actual services you receive from mental health specialists during your stay.
How Length of Stay Impacts Medicare Coverage
Due to Medicare coverage limitations, the length of your stay in any eligible care facility directly affects your coinsurance costs. Medicare inpatient benefit periods last 90 days, starting when you enter inpatient care and resetting 60 days after your initial discharge. If your stay does exceed 90 days, Medicare grants you 60 extra “lifetime reserve days” that expire after use. So if you stay in the hospital for 120 consecutive days, you permanently use up 30 of your lifetime reserve days.
Length of Stay | Coinsurance Cost |
|---|---|
1-60 days | $0. |
61-90 days | $400 per additional day. |
91 days and beyond | $800 per each “lifetime reserve day.” |
Beyond Lifetime Reserve Days | No coinsurance. You pay the total cost of care out of pocket. |
This table refers explicitly to coinsurance rates for stays in Medicare-approved hospitals. Charges may register differently for other eligible care centers. For example, Medicare covers the first 20 days of care at a skilled nursing facility, imposes a $200 copay between days 21-100, and stops providing coverage after day 100.
What Inpatient Services Are Not Covered By Medicare?
While both parts of Original Medicare combine to help pay for most medically necessary inpatient care, they exclude some items and services from coverage. These include:
- A private room (unless deemed medically necessary by a doctor)
- Personal items, such as razors or socks
- Private-duty nurses that perform one-on-one tailored care, including assistance with activities of daily living like bathing or dressing
- A television or phone not already included in the room
- Excessive or unnecessary treatments or testing
- Any inpatient stay exceeding Medicare length of stay limits
- Voluntary euthanasia
However, in rare instances, a few select hospitals may offer these and similar features at no extra charge.
How Do Other Medicare Options Cover Hospital Stays?
After Medicare Part A covers the essentials of an inpatient stay, like a semi-private room and medical supplies, you will still need to account for specialized doctor’s services and all relevant coinsurance and deductible charges. Expenses outside of Part A parameters usually qualify for coverage under Medicare Part B or through some Medicare Advantage and Medicare Supplement plans.
Medicare Part B
Medicare Part B generally covers outpatient medical care, which includes most doctors’ services, but also pays for procedures performed by doctors or specialists in an inpatient facility. Care must qualify as medically necessary for Part B coverage, thus excluding procedures like cosmetic surgery, chiropractor services, and most dental or vision work.
Even with Part B coverage, you still must pay for some care out of pocket. Medicare set its Part B deductible at $226 for 2023, which you must pay before Medicare starts to pay. After that, Medicare will pay 80% of all covered services and durable medical equipment, leaving you with a 20% coinsurance.
Doctors must “accept assignment” for Part B coverage, asserting they agree to the Medicare-approved amount for service. Doctors outside this purview can bill up to 15% higher than the Medicare-approved amount, due along with your deductible and coinsurance.
Medicare Advantage
Medicare Advantage plans must provide equal coverage to Original Medicare and may occasionally extend their reach to include dental work, some prescription drugs, and more. Therefore, Medicare Advantage must help cover inpatient stays up to 90 days per benefit period, though some plans may offer additional coverage beyond that timeframe.
Because private companies oversee Medicare Advantage plans, they can impose exclusive copays, deductibles, and coinsurance charges and restrict your network of eligible doctors. Nevertheless, Medicare Advantage plans must cap annual out-of-pocket spending at $8,300 per patient, taking on total financial responsibility for all services exceeding that limit
Medicare Supplement (Medigap)
Private companies may offer Medicare Supplement, or Medigap, plans to help fill payment gaps in Original Medicare coverage. Following an inpatient hospital stay, patients typically utilize Medigap to help pay down deductibles and coinsurance left by Medicare Part A. In some cases, Medigap may even cover the first three pints of a blood transfusion.
Ten different Medigap plan types exist, labeled A through N (e.g., Medigap Plan F), each with exclusive terms. Corresponding plan types employ standardized coverage regardless of the company that provides them, though premiums and available policies will vary based on your location. Beneficiaries cannot have both Medigap and Medicare Advantage together at the same time.
How to Get Inpatient Coverage with Medicare
To ensure you receive full Medicare coverage for a hospital stay, follow these simple guidelines before admitting yourself to the hospital or a similar inpatient facility.
1. Find a Medicare-Approved Facility
For guaranteed coverage, you must receive care at a Medicare-approved facility. Luckily, over 4,000 hospitals accept Medicare, not-to-mention skilled nursing facilities, rehabilitation centers, and psychiatric care hospitals. Use the official Medicare providers portal to find an eligible care center near you.
2. Obtain an Official Doctor’s Order
Medicare will only cover services certified as medically necessary, meaning a doctor must determine that you require inpatient hospital care to recover properly from injury or ailment. Ask your doctor for a signed document explaining your condition, why it needs inpatient attention, the estimated duration of your visit, and any plans for post-hospital care.
3. Receive Care
Once you secure a doctor’s order, you can begin receiving care. Remember that you must pay the Part A deductible and any eligible coinsurance for extended stays or doctor’s services covered by Part B.
Finally, save your discharge planning documents to help you transition smoothly from one care center to another and to have evidence for any potential Medicare-related disputes later on.
Alternative Options for Hospital Coverage
Unfortunately, few options outside private or public health insurance exist to help cover hospital charges. Uninsured individuals would have to find some way to shoulder inpatient fees out of pocket or can research free clinics and local community health centers that might suffice for temporary care.
If you do not have Medicare or ACA health coverage, try applying for a medical credit card or ask your hospital about a payment plan to help finance qualified healthcare expenses. Federal law also requires non-profit hospitals to provide some charity care in exchange for their tax-exempt status, so check with your care center about this before resorting to your bank account.
All in All
Depending on the length of your visit, home state, and level of care, daily rates for an inpatient hospital stay can stack up rapidly. Upon meeting your deductible, Medicare Part A will cover the first 60 days of your visit, tentatively saving you tens of thousands of dollars in medical fees. Part A coverage extends to similar eligible care centers, including skilled nursing facilities and rehabilitation centers, each with its own coverage limits and coinsurance rates.
Once ready, take the first steps toward coverage by speaking with a licensed Medicare agent to sort out your cost breakdown and policy details. Or, simply compare plans online.