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Your Health
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David Sayen: What Medicare Covers in the Hospital

Enrollment in Parts A and B will provide a full range of benefits

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?

David Sayen
David Sayen

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 inpatient or an outpatient. Staying overnight in a hospital doesn’t always mean you’re an inpatient. You’re an inpatient on the day the doctor formally admits you, with a doctor’s order.

If you aren’t sure whether you’re an inpatient or an outpatient, ask your doctor or the hospital staff. Or you can call Medicare at 800.633.4227.

If you’re admitted as an inpatient, 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 inpatient 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 800.633.4227. 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 (such as toothpaste or razors) or a private room, unless it’s medically necessary.

For hospital outpatient care, you pay a co-payment for each individual outpatient 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 inpatient hospital deductible.

I’ve very much enjoyed bringing you Medicare information during the past year, and I hope you and your family have a happy and healthy holiday season!

— David Sayen is the regional administrator for California, Arizona, Hawaii, Nevada and the Pacific Trust Territories for the U.S. Centers for Medicare & Medicaid Services. For answers to Medicare questions 24/7, call 800.633.4227.

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