Editing Medicare (United States) (section)

===Part A: Hospital/hospice insurance===
Part A covers [[Inpatient care|inpatient]] [[hospital]] stays. The maximum length of stay that Medicare Part A covers in a hospital admitted inpatient stay or series of stays is typically 90 days. The first 60 days would be paid by Medicare in full, except one copay (also and more commonly referred to as a "deductible") at the beginning of the 60 days of $1632 as of 2024.<ref name=":1">{{Cite web |title=2024 Medicare Parts A & B Premiums and Deductibles {{!}} CMS |url=https://www.cms.gov/newsroom/fact-sheets/2024-medicare-parts-b-premiums-and-deductibles |access-date=2024-08-15 |website=www.cms.gov}}</ref> Days 61–90 require a co-payment of $408 per day as of 2024.<ref name=":1" /> The beneficiary is also allocated "lifetime reserve days" that can be used after 90 days. These lifetime reserve days require a copayment of $816 per day as of 2024, and the beneficiary can use a total of only 60 of these days throughout their lifetime.<ref name="medicare-costs-2023-2024">{{cite web |title=Costs Medicare |url=https://www.medicare.gov/basics/costs/medicare-costs |website=www.medicare.gov |publisher=Medicare |access-date=16 December 2023}}</ref> A new pool of 90 hospital days, with new copays of $1632 in 2024 and $408 per day for days 61–90, starts only after the beneficiary has 60 days continuously with no payment from Medicare for hospital or Skilled Nursing Facility confinement.<ref>{{cite web|url=http://www.medicare.gov/glossary/b.html|title=Benefit period|publisher=Medicare|access-date=April 26, 2018|archive-date=March 10, 2021|archive-url=https://web.archive.org/web/20210310222928/https://www.medicare.gov/glossary/b.html|url-status=dead}}</ref>

Some "hospital services" are provided as inpatient services, which would be reimbursed under Part A; or as outpatient services, which would be reimbursed, not under Part A, but under Part B instead. The "Two-Midnight Rule" decides which is which. In August 2013, the [[Centers for Medicare and Medicaid Services]] announced a final rule concerning eligibility for hospital inpatient services effective October 1, 2013. Under the new rule, if a physician admits a Medicare beneficiary as an inpatient with an expectation that the patient will require hospital care that "crosses two midnights", Medicare Part A payment is "generally appropriate". However, if it is anticipated that the patient will require hospital care for less than two midnights, Medicare Part A payment is generally not appropriate; payment such as is approved will be paid under Part B.<ref>{{cite journal |last=Hord|first=Emily M.|publisher=McBrayer, McGinnis, Leslie & Kirkland|title=Clarifying the 'Two-Midnight Rule' and Part A Payments Re: Inpatient Care|journal=The National Law Review|volume=III|issue=253|date=September 10, 2013|url=http://www.natlawreview.com/article/clarifying-two-midnight-rule-and-part-payments-re-inpatient-care|access-date=June 29, 2022}}</ref> The time a patient spends in the hospital before an inpatient admission is formally ordered is considered outpatient time. But, hospitals and physicians can take into consideration the pre-inpatient admission time when determining if a patient's care will reasonably be expected to cross two midnights to be covered under Part A.<ref>{{cite journal|last=Hord|first=Emily M.|title=Clarifying the "Two-Midnight Rule" and Part A Payments, cont.|journal=The National Law Review|date=September 12, 2013|url=http://www.natlawreview.com/article/clarifying-two-midnight-rule-and-part-payments-cont}}</ref> In addition to deciding which trust fund is used to pay for these various outpatient versus inpatient charges, the number of days for which a person is formally considered an admitted patient affects eligibility for Part A skilled nursing services.

Medicare penalizes hospitals for [[Hospital Readmission|readmissions]]. After making initial payments for hospital stays, Medicare will take back from the hospital these payments, plus a penalty of 4 to 18 times the initial payment, if an above-average number of patients from the hospital are readmitted within 30 days. These readmission penalties apply after some of the most common treatments: [[pneumonia]], [[heart failure]], [[heart attack]], [[COPD]], [[knee replacement]], and [[hip replacement]].<ref>{{cite web|url=http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html |title=Readmissions Reduction Program, seen June 25, 2013 |website=Cms.gov |access-date=August 30, 2013}}</ref><ref>{{cite web|url=http://www.kaiserhealthnews.org/stories/2013/march/14/revised-readmissions-statistics-hospitals-medicare.aspx |title=Kaiser health News, Medicare Revises Readmissions Penalties – Again |website=Kaiserhealthnews.org |date=March 14, 2013 |access-date=August 30, 2013}}</ref> A study of 18 states conducted by the [[Agency for Healthcare Research and Quality]] (AHRQ) found that 1.8 million Medicare patients aged 65 and older were readmitted within 30 days of an initial hospital stay in 2011; the conditions with the highest readmission rates were congestive heart failure, [[sepsis]], pneumonia, and COPD and [[bronchiectasis]].<ref>{{cite journal | vauthors = Hines AL, Barrett ML, Jiang HJ, Steiner CA | title = Conditions With the Largest Number of Adult Hospital Readmissions by Payer, 2011. | journal =HCUP Statistical Brief |issue=172 | publisher = Agency for Healthcare Research and Quality | location = Rockville, MD | date = April 2014 | pmid = 24901179 | url = http://hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.jsp | access-date = May 21, 2014 | archive-date = March 4, 2016 | archive-url = https://web.archive.org/web/20160304052719/http://hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.jsp | url-status = dead }}</ref>

The highest penalties on hospitals are charged after knee or hip replacements, $265,000 per excess readmission.<ref>{{cite web|url=http://ehrintelligence.com/2013/08/15/knee-and-hip-replacement-readmissions-may-cost-265000/|title=Knee and hip replacement readmissions may cost $265,000 |publisher=EHR Intelligence |access-date=August 24, 2013|date=August 15, 2013 }}</ref> The goals are to encourage better post-hospital care and more referrals to hospice and end-of-life care in lieu of treatment,<ref>{{cite web|url=http://www.medpac.gov/documents/Mar12_EntireReport.pdf |title=Report to Congress, Medicare Payment Policy. March 2012, pp. 195–96 |publisher=MedPAC |access-date=August 24, 2013 |url-status=dead |archive-url=https://web.archive.org/web/20131019105819/http://www.medpac.gov/documents/Mar12_EntireReport.pdf |archive-date=October 19, 2013 }}</ref><ref>{{cite web|url=http://www.fha.org/showDocument.aspx?f=FHA5YearsOnlineversion.pdf|title=Five Years of Quality, p. 8|publisher=Florida Hospital Association|access-date=August 24, 2013|archive-date=February 27, 2021|archive-url=https://web.archive.org/web/20210227015108/http://www.fha.org/showDocument.aspx?f=FHA5YearsOnlineversion.pdf|url-status=dead}}</ref> while the effect is also to reduce coverage in hospitals that treat poor and frail patients.<ref>{{Cite journal | doi=10.1056/NEJMp1201598 | title=Thirty-Day Readmissions – Truth and Consequences | year=2012 | last1=Joynt | first1=Karen E. | last2=Jha | first2=Ashish K. | journal=New England Journal of Medicine | volume=366 | issue=15 | pages=1366–69 | pmid=22455752}}</ref><ref>{{cite journal|title=Thirty-day readmissions—truth and consequences|pmid=22455752|year=2012|last1=Joynt|first1=KE|last2=Jha|first2=AK|volume=366|issue=15|pages=1366–9|doi=10.1056/NEJMp1201598|journal=The New England Journal of Medicine}}</ref> The total penalties for above-average readmissions in 2013 are $280 million,<ref>{{cite web|url=https://www.federalregister.gov/articles/2012/08/31/2012-19079/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the#h-22 |title=Summary of Costs and Benefits |website=Federalregister.gov |date=August 31, 2012 |access-date=August 30, 2013}}</ref> for 7,000 excess readmissions, or $40,000 for each readmission above the US average rate.<ref>{{cite web |url=http://globe1234.com |archive-url=https://archive.today/20130624212152/http://globe1234.com/ |url-status=dead |archive-date=June 24, 2013 |title=Math Underlying the Penalties |website=Globe1234.com |date=July 18, 2013 |access-date=August 30, 2013 }}</ref>

Part A fully covers brief stays for rehabilitation or convalescence in a [[skilled nursing facility]] and up to 100 days per medical necessity with a co-pay if certain criteria are met:<ref name="medicare-costs-2023-2024"/><ref name="Kodjak">{{cite news |last1=Kodjak |first1=Alison |author-link1=Alison Kodjak |title=How Medicare's Conflicting Hospitalization Rules Cost Me Thousands Of Dollars |url=https://www.npr.org/sections/health-shots/2018/04/20/583338114/how-medicares-conflicting-hospitalization-rules-cost-me-thousands-of-dollars |access-date=2019-01-01 |publisher=NPR |date=2018-04-20}}</ref>

# A preceding hospital stay must be at least three days as an inpatient, three midnights, not counting the discharge date.
# The skilled nursing facility stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay.
# If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision (e.g., wound management) then the nursing home stay would be covered.
# The care being rendered by the nursing home must be skilled. Medicare part A does not pay for stays that ''only'' provide custodial, non-skilled, or [[long-term care]] activities, including [[activities of daily living]] (ADL) such as personal hygiene, cooking, cleaning, etc.
# The care must be medically necessary and progress against some set plan must be made on some schedule determined by a doctor.

The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment of $204 per day as of 2024.<ref name="medicare-costs-2023-2024" /> Many [[insurance]] group retiree, Medigap and Part C insurance plans have a provision for additional coverage of skilled nursing care in the indemnity insurance policies they sell or health plans they sponsor. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 90-day hospital clock and 100-day nursing home clock are reset and the person qualifies for new benefit periods.

[[Hospice]] benefits are also provided under Part A of Medicare for terminally ill persons with less than six months to live, as determined by the patient's physician. The terminally ill person must sign a statement that hospice care has been chosen over other Medicare-covered benefits, (e.g. [[assisted living]] or hospital care).<ref>[http://www.medicare.com/assisted-living/hospice-care.html Medicare Guide to Covered Products, Services and Information] {{webarchive|url=https://web.archive.org/web/20140209113031/http://medicare.com/assisted-living/hospice-care.html |date=February 9, 2014 }}. Medicare.com. Retrieved on July 17, 2013.</ref> Treatment provided includes pharmaceutical products for symptom control and pain relief as well as other services not otherwise covered by Medicare such as [[grief counseling]]. Hospice is covered 100% with no co-pay or deductible by Medicare Part A except that patients are responsible for a copay for outpatient drugs and respite care, if needed.<ref name="medicare">{{cite web|url=http://www.medicare.gov/publications/pubs/pdf/hosplg.pdf |title=Medicare Hospice Benefits |publisher=Medicare, the Official U.S. Government Site for People with Medicare |date=March 2000 |access-date=February 1, 2009 |url-status=dead |archive-url=https://web.archive.org/web/20090306191044/http://www.medicare.gov/publications/pubs/pdf/hosplg.pdf |archive-date=March 6, 2009 }}</ref>

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