Medicare Part A

Eligibility through SSDI

After you get your first Social Security Disability Insurance (SSDI) payment, you have to wait two years before your Medicare benefits begin. Around the 20th month after getting an SSDI (or CDB) benefit, you should get a notice in the mail telling you that your Medicare benefits are going to start soon.

You will automatically be signed up for Medicare Part A, and you won’t have to pay a premium for it. You’ll also get a card in the mail that says that you are entitled to Medicare Part A. The card may also say you’re entitled to Medicare Part B.

Other Ways to Qualify

For those who are under 65, you can get Medicare Part A without paying a premium if you are in one of the following categories:

  • You get or are eligible for SSDI or Childhood Disability Benefits (CDB).
  • You get or are eligible for Railroad Retirement Board disability benefits.
  • You have End Stage Renal Disease (kidney dialysis or transplant patients) and meet certain requirements.
  • You have Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease).
  • You have worked in a government job and meet the requirements for SSDI.

In some cases, if they have a disability, widows and widowers, divorced widows and widowers, and children may be eligible for Medicare.

For those who are 65 and older, you can get Medicare Part A without a premium if you are in one of the following categories:

  • You get or are eligible for Social Security retirement benefits.
  • You get or are eligible for Railroad Retirement Board retirement benefits.
  • You have worked in a government job that qualifies you for Medicare.

In some cases, spouses, divorced spouses, widows, widowers, and parents may be eligible based on their work record when they turn 65.

If you are over 65 and don’t qualify for free Part A, you can pay a premium for it.

The Benefit

Medicare Part A helps pay for:

Care You Get When Admitted to the Hospital

Part A will help pay for a semi-private room, general nursing, meals, drugs that you get as an inpatient, and other services and supplies. This includes mental health care in a hospital or specialty psychiatric hospital.

Short-term Stays in a Skilled Nursing Facility

Part A will help pay for your stays at Skilled Nursing Facilities, where you get daily skilled care from nurses or rehabilitation specialists. You can think of this as short-term care you get after you’ve been stabilized in a hospital.

Examples of skilled nursing care include intravenous injections, changing sterile dressings, and physical therapy a minimum of five times per week.

A medical social worker can help you when you move back home. Skilled nursing does not include what Medicare calls “custodial care” which is help with daily tasks like walking, eating, or bathing.

Example:
You have a stroke. When you leave the hospital, you are transferred to a Skilled Nursing Facility where you receive physical, occupational, and speech therapy to help you recover and gain independence.

Hospice Care

Hospice care is care that you receive when you have a terminal diagnosis. Medicare Part A will help pay for drugs and other support services when, according to your physician, you have six months or less to live. If you live beyond six months, your hospice benefits can be extended.

Home Health Care Services

Medicare certifies some agencies to provide home health care services. These are things like nursing services and physical, occupational, and speech therapy that you get in your home. Home Health Agencies also might help pay for medical social services or equipment like wheelchairs, beds, and walkers to use at home.

Blood

Usually hospitals get blood at no charge. If they do have to buy blood for your transfusion, Medicare will help after you’ve paid for the first three pints of blood.

Medically Necessary Coverage

As with other aspects of the Medicare program, Part A's general guideline is that it will help pay for what is medically necessary. Having a television in your hospital room, for example, is not considered medically necessary, so Medicare won’t pay for it.

Medicare does not generally help pay for long-term care. Long-term care usually includes help with things like bathing, getting dressed, and using the bathroom. You might get this help in your home, somewhere in the community, or at a Skilled Nursing Facility. Medi-Cal may help pay for these costs if you qualify.

The California Health Advocates website has an excellent section on long-term care.

What You Pay

Medicare Part A doesn’t pay for 100% of your expenses. The services it pays for, and the percentage of the cost it covers, depend on what services you get and when you get them.

Hospital Stays

Let’s say that you have Medicare Part A and have never been in the hospital before. You get sick and are admitted to a hospital for 100 days. The rules for how much you have to pay and how much Medicare will pay change throughout your stay.

For days 1 – 60, you’ll have to pay a total of $1,316 before Medicare will begin to help pay for your costs. After that, Medicare will pay for all of your reasonable and necessary hospital costs for days 1 – 60.

For days 61 – 90, you will have to pay $329 per day, and Medicare will pay for the rest of your reasonable and necessary costs.

After the 90 days are up, you have two options:

  • Option 1 is to use one of your lifetime reserve days. You get 60 of these days over the course of your life. With your lifetime reserve days, you pay $658 per day and Medicare pays for the rest of your reasonable and necessary costs for those days.
  • Option 2 is to pay for the cost yourself and not use up one of your lifetime reserve days. Let’s say that you decide to use 10 of your lifetime reserve days.
Hospital Stays: Who Pays What

You Pay:

For Covered Service, Medicare Part A Pays:

Days 1-60

The first $1,316

The rest

Days 61-90

$329 per day

The rest

Days 91-150 (using your 60 lifetime reserve days)

$658 per day

The rest

Days 151+ (or other days after day 90 that you don’t use your lifetime reserve days)

Everything

Nothing

What if you have to go back to the hospital?

This is when the concept of a benefit period comes into play. A benefit period ends when you haven’t been to the hospital (or Skilled Nursing Facility) for 60 days in a row.

The rules above actually apply to days within a benefit period. Continuing the example above, let’s look at two scenarios:

  1. Scenario One: You’re released from the hospital, but have to return a week later for another 10 day stay.
  2. Scenario Two: You’re released from the hospital, but have to return 61 days later for another 10 day stay.
Scenario One:
In this scenario, 60 days have not gone by between the end of your first hospital stay and the beginning of your second, so you’re still in the same benefit period. Another way of thinking about this is that, as far as Medicare is concerned, you are on days 101 – 110 of your original hospital stay.
You've already paid your deductible for the benefit period, and you've already used up days 61 – 90 (the days that Medicare pays for all but $329 of your reasonable and necessary costs). That means you can either use lifetime reserve days or pay out of pocket. If you decide to use another 10 lifetime reserve days, you’ll have used up 20 of your 60.

Scenario Two:
In this scenario, more than 60 days have passed between the end of your first hospital stay and the beginning of your second. This means that you are in a new benefit period, so you will start again on day zero and have to pay the deductible of $1,316 before Medicare will cover your costs.

You can have an unlimited number of benefit periods in your life. The exception is that you can only have a lifetime total of 190 days in an inpatient psychiatric hospital.

Skilled Nursing Facilities

Let’s say that you were hospitalized for a stroke and need to go to a Skilled Nursing Facility for rehabilitation. In order for Medicare to help pay for the Skilled Nursing care, you have to have been in a hospital for a related illness (in this case the stroke) for at least 3 days, not including the date you were discharged from the hospital.

If you meet that requirement, are admitted to a Skilled Nursing Facility within 30 days of hospital discharge, and receive daily skilled nursing or rehab services, for each benefit period Medicare will pay for:

  • All covered costs for days 1 – 20.
  • Costs for days 21 – 100 (except for the first $164.50 each day – you pay for that).
  • Nothing after day 100.

Other Medicare Part A Services

For hospice care, you pay $5 for outpatient prescription drugs and 5% of the costs for respite care.

For home health care, Medicare pays for the entire approved amount of home health services and 80% of the costs of durable medical equipment.

For blood received as an inpatient that the hospital has to buy, you have to pay the entire cost of the first three pints. After that, Medicare will pay for 80% of the cost of subsequent pints. Usually, hospitals don’t have to buy blood, so you don’t get charged. Another option is to donate pints to replace the blood you need.

Help Paying for Part A Costs: Medicare Savings Programs

If you have low income and assets, you may be eligible to have California's Medi-Cal program pay for some of your Medicare Part A costs through a Medicare Savings Program.

The Qualified Medicare Beneficiary (QMB) program pays for Medicare Part A and Part B premiums, coinsurance, copayments, and deductibles. To qualify, you must:

  • Be eligible for or enrolled in Medicare Part A;
  • Have countable income at or below 100% of the Federal Poverty Level ($1,005 per month, $1,353 for couples);
  • Have assets at or below the limit ($7,390 for individuals, $11,090 for couples); and
  • Meet all other Medi-Cal eligibility requirements.

This program does not apply benefits retroactively, which means that you can’t get help paying for costs for past months.

The Qualified Disabled Working Individual (QDWI) program pays for Medicare Part A premiums. The QDWI program is for Social Security Disability Insurance (SSDI) beneficiaries who lose their free Medicare Part A because they are earning too much money. To qualify, you must:

  • Be less than 65 years old;
  • Be eligible for Medicare Part A;
  • Have countable income at or below 200% of the Federal Poverty Level ($2,010 per month, $2,707 for couples);
  • Have assets at or below the limit ($4,000 for individuals, $6,000 for couples), and
  • Meet all other Medi-Cal eligibility requirements.

For both programs, it is important to know that not all of your income counts. The same is true for your assets. The home where you live, burial funds, and your car, for example, don’t count as assets.

Call your county Health Insurance Counseling & Advocacy Program (HICAP) office to learn more about whether you qualify for a Medicare Savings Program. If you do, they'll explain how to apply at your local county social services agency.

Part A and Returning to Work

If people under 65 who are getting Part A through SSDI don’t go back to work, their SSDI automatically changes to retirement insurance when they reach their full retirement age. They get to keep their free Medicare Part A. But, if you go back to work earlier, things can change before then.

A Trial Work month is any month that an SSDI recipient works and earns over a certain amount ($840 in 2017).

The rules about your Medicare coverage are directly tied to SSDI’s work rules. SSDI allows you to attempt to return to work without losing your benefits. First, you get a Trial Work Period. Once you use 9 Trial Work months, your Trial Work Period is over. See DB101's SSDI Work Rules FocusPopup Link for a detailed example of how the Trial Work Period works.

The end of your Trial Work Period is an important marker in terms of your Medicare coverage. After your Trial Work Period, you get 93 more months (almost 8 years) of premium-free Medicare Part A coverage, as long as Social Security finds that you still have a medical disability.

Example:
Your last Trial Work month is September 2008. As long as you stay medically disabled, you will continue to get premium-free Medicare Part A until at least June 30, 2016.

The actual date that your Medicare ends depends on how much you are earning in the period after your Trial Work Period, but it will be at least 93 months as long as you are still medically disabled.

Even after you lose your premium-free Part A coverage, you can decide to pay the Part A monthly premium ($413 in 2017) to keep your coverage. If your income and assets meet certain limits, you may be eligible to pay a lower premium or to have Medi-Cal pay for your Medicare Part A premium through the Qualified Medicare Beneficiary (QMB) program. If you do have to pay a premium, it will be lowered to $227 if you were employed for long enough.