Hospitals and Medicare
Many of us may need hospital care at some point in our lives. It’s important to understand what type of Medicare hospital coverage you’re eligible for and what benefits you’re entitled to under Original Medicare, Part A and Part B.
Hospitals provide inpatient and outpatient services through specialized staff and equipment. They are staffed by physicians, surgeons, and nurses. Hospital care includes treatment that you receive in the following types of facilities:
- Acute care hospital
- Critical access hospital
- Inpatient rehabilitation facility
- Long-term care hospital
- Qualifying research study
- Psychiatric hospital
If you need inpatient care, the length of your hospital stay may vary, depending on the seriousness of your condition and the type of care you need. If you require a longer hospital stay, you may be transferred to a long-term care hospital, which is a facility that specializes in treating patients who need more time to recover. Patients who enter these facilities are often transferred from the intensive-care unit of a general hospital. Long-term care hospitals specialize in treating individuals with particularly serious conditions and may offer specialized rehabilitative, trauma, and pain management services.
Eligibility for hospital coverage
Medicare will cover your inpatient hospital stay if you meet all of these requirements:
- You are enrolled in Medicare Part A.
- Your participating Medicare doctor orders two or more midnights of medically necessary inpatient hospital care for your illness or injury and you are formally admitted by the hospital.
- The care you need requires a hospital stay.
- You go to a hospital that participates in the Medicare program and accepts Medicare.
- Your stay is approved by the hospital’s Utilization Review Committee during your hospital stay.
Medicare benefits for hospital stays
If you need hospital services, keep in mind that your hospital status affects whether you’re covered through Medicare Part A or Part B and the costs you pay. Your hospital status may also affect whether you’re covered for skilled nursing facility (SNF) care after your hospital stay, since Medicare only covers SNF care after a qualifying three-day inpatient hospital stay. If you’re admitted to the hospital as an inpatient, you’ll be covered under Medicare Part A. If you’re getting outpatient surgery, observation services, or other doctor services in a hospital, you’ll be covered by Medicare Part B. Remember, an overnight hospital stay doesn’t mean you have an inpatient status if the hospital hasn’t formally admitted you as an inpatient.
Medicare Part A: If you’re admitted to the hospital as an inpatient, Medicare hospital coverage generally includes (but isn’t limited to):
- A semi-private (shared) room
- Nursing care
- Drugs given as part of your treatment
Medicare Part B: Medically necessary outpatient services are covered through Medicare Part B, even if you receive them in a hospital setting. Medicare Part B may cover services and supplies such as:
- Ambulance transportation
- Durable medical equipment, like walkers
- Doctor visits
- Preventive services
- Second opinions on surgeries
- Lab tests
- X-rays and other scans
Hospital services not covered by Medicare
Original Medicare, Part A and Part B, doesn’t cover the costs of private-duty nursing, a phone or television, personal items (like toothpaste), or a private room (unless a private room is medically necessary).
Medicare Part A generally covers drugs given to you during your inpatient hospital stay. Medicare Part B offers limited prescription coverage for drugs that are administered in a hospital outpatient setting or a doctor’s office.
If you’re an outpatient, Medicare doesn’t usually cover the prescription drugs that you can “self-administer” (take by yourself). You may be able to get these medications covered through a stand-alone Medicare Prescription Drug Plan (Part D) or a Medicare Advantage Prescription Drug plan. Call your Medicare plan for more information.
Costs and benefits for hospital services
Costs for hospital care such as deductibles, copayments, and/or coinsurance may change from year to year. For the most up-to-date cost information, visit Medicare.gov.
Under Medicare Part A, your costs for an inpatient hospital stay include:
- A one-time hospital deductible, but no coinsurance, for days 1-60 during each benefit period.
- A coinsurance amount per day for days 61-90 during each benefit period.
- A coinsurance amount for each lifetime reserve day.
- All costs for each day after you’ve used all of your lifetime reserve days.
- If you require an inpatient psychiatric hospital stay, Medicare Part A will pay for up to 190 days of inpatient psychiatric hospital care in your lifetime.
Under Medicare Part B:
- In general, you pay 20% of the Medicare-approved amount for most doctor services you receive when you’re a hospital inpatient or outpatient.
- For hospital outpatient services, you pay a copayment for each individual outpatient hospital service.
- The copayment can be different for each service, but never more than the Part A hospital deductible.
- In some cases, your total copayments for all covered hospital outpatient department services may be more than the inpatient hospital deductible.
Medicare Advantage plans are required to cover at least the same level of benefits as Original Medicare; however, these plans may have different costs. Check with your individual plan for more information on costs for hospital care.