Which part of medicare covers inpatient hospital charges

The cost of hospital care can be daunting. Fortunately, if you have Medicare Part A (hospital insurance), it generally covers inpatient surgery. Medicare Part B (medical insurance) may cover some services while you’re an inpatient, as well. Here’s how this Medicare coverage works.

What is an inpatient surgery?

Inpatient surgery refers to surgery performed in the hospital after a doctor has admitted you as an inpatient. Your doctor may order an inpatient surgery during a hospital stay or may schedule surgery in advance of your hospital admission.

It is important to understand that you can be getting care in a hospital and still be an outpatient, not an inpatient. Your Medicare coverage and out-of-pocket costs are different for outpatient and inpatient surgery.

When does Medicare cover inpatient surgery?

Your inpatient surgery must meet two basic requirements for Medicare coverage:

  • The hospital and physicians performing the inpatient surgery accept Medicare
  • Inpatient surgery must be medically necessary. Medicare defines “medically necessary” as “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
  • In certain cases, the Utilization Review Committee of the hospital approves your stay while you’re in the hospital.

If you’re enrolled in a Medicare Advantage plan, the plan may also require the hospital and doctors providing inpatient surgery to participate in the plan’s provider network as a condition of coverage.

If your inpatient surgery meets Medicare requirements, Medicare Part A and Medicare Advantage plans typically pay for covered hospital services. Hospital services related to inpatient surgery usually include daily room and board, laboratory services, diagnostic tests, surgical equipment and supplies, anesthesia, and the services of doctors, nurses, and other health professionals.

Medicare Part B and Medicare Advantage plans generally cover physician services, including surgeons and anesthesiologists who participate in the inpatient surgery but who are not employees of the hospital.

What can you expect to pay for an approved inpatient surgery?

Medicare Part A generally covers much of the cost related to your inpatient surgery and hospital stay. You may be responsible for a Medicare Part A deductible ($1,600 in 2023) for each benefit period. Medicare defines a benefit period as beginning the day you’re admitted as an inpatient in a hospital or skilled nursing facility (SNF) and ending when you have not received any inpatient hospital or SNF care for 60 days in a row. You pay this inpatient hospital deductible amount for each benefit period.

The amount you may pay for inpatient surgery can also depend on your recovery time. You won’t typically pay a Medicare Part A coinsurance amount if your inpatient stay lasts between one and 60 days. However, if you spend more time in the hospital for inpatient surgery, you have to pay a coinsurance amount.

  • You will pay $400 per day (in 2023) per benefit period for days 61 to 90.
  • You will be liable for $778 (in 2023) per benefit period for every “lifetime reserve” day you spend in the hospital beyond 90 days.
  • If you are still in the hospital after exhausting your “lifetime reserve days,” Medicare Part A generally will not continue coverage for your hospital expenses.

Medicare Part B usually pays 80 percent of the Medicare-approved amount for doctors’ services billed separately from the hospital’s charges for inpatient surgery. You are responsible for 20% after you have met the Part B annual deductible ($226 in 2023).

If you have a Medicare Supplement (Medigap) plan, it may cover some out-of-pocket costs related to your inpatient surgery. All of the Medicare Supplement plans standardized in 47 states may pay the Part A coinsurance on long hospital stays (for an additional 365 days after Medicare coverage is used up). Many also cover all or a portion of Part B coinsurance and Part A and Part B deductibles.

If you have a Medicare Advantage plan, specific inpatient deductibles, coinsurance, and copayments for inpatient surgery may be different from Medicare Part A and Part B cost shares. You can contact the plan’s customer service for coverage information.

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  • Medicare Part A can help provide coverage for hospital stays.
  • You’ll still be responsible for deductibles and coinsurance.

A stay at the hospital can make for one hefty bill. Without insurance, a single night there could cost thousands of dollars. Having insurance can help reduce that cost.

If you’re eligible for Medicare, Medicare Part A can provide some coverage for inpatient care and significantly reduce costs for extended hospital stays. But in order to receive the full scope of benefits, you may need to pay a portion of the bill.

Keep reading to learn more about Medicare Part A, hospital costs, and more.

Medicare Part A, the first part of original Medicare, is hospital insurance. It typically covers inpatient surgeries, bloodwork and diagnostics, and hospital stays.

Part A also includes coverage for:

  • blood transfusions when done during a hospital stay
  • limited skilled nursing facility care
  • limited home healthcare
  • hospice care

If admitted into a hospital, Medicare Part A will help pay for:

  • the hospital room
  • nursing services
  • meals
  • medications
  • medical supplies
  • durable medical equipment used while in hospital care, like wheelchairs, walkers, and crutches
  • diagnostic testing
  • rehabilitation services provided while an inpatient

Even with insurance, you’ll still have to pay a portion of the hospital bill, along with premiums, deductibles, and other costs that are adjusted every year.

In 2020, the Medicare Part A deductible is $1,408 per benefit period.

Medicare Part A deductible

Unlike some deductibles, the Medicare Part A deductible applies to each benefit period. This means it applies to the length of time you’ve been admitted into the hospital through 60 consecutive days after you’ve been out of the hospital.

So, if you’re discharged from the hospital and return within the 60-day period, you don’t need to pay another deductible.

If you’re admitted after the 60-day period, then you’ve started another benefit period and you will be expected to pay another deductible.

Medicare Part A coinsurance

Once the deductible is paid fully, Medicare will cover the remainder of hospital care costs for up to 60 days after being admitted.

If you need to stay longer than 60 days within the same benefit period, you’ll be required to pay a daily coinsurance. The coinsurance applies to an additional 30-day period — or days 61 through 90 if counted consecutively.

As of 2020, the daily coinsurance costs are $352.

After 90 days, you’ve exhausted the Medicare benefits within the current benefit period. At that point, it’s up to you to pay for any other costs, unless you elect to use your lifetime reserve days.

A more comprehensive breakdown of costs can be found below.

Breakdown of deductible and coinsurance fees

Medicare provides an additional 60 days of coverage beyond the 90 days of covered inpatient care within a benefit period. These 60 days are known as lifetime reserve days.

Lifetime reserve days can be used only once, but they don’t have to be used all in one hospital visit. For example, if you have two extended hospital stays, each amounting to 120 days, you can use 30 lifetime reserve days for each period.

Using lifetime reserve days will come at a higher cost or coinsurance. The 2020 coinsurance cost for these days is $704.

If you paid Medicare taxes during your working years, you may qualify for premium-free Medicare Part A. To be eligible, you’ll need to have worked for 40 quarters, or 10 years, and paid Medicare taxes during that time.

If you haven’t met that benchmark and have to pay monthly premiums, you can expect to pay $458 per month in 2020.

Another option for hospital coverage is a Medicare Advantage (Part C) plan. These plans are offered through private providers and include all benefits covered through original Medicare (Part A and Part B).

These plans often include extra benefits, too, such as Medicare Part D (prescription drug coverage). They may also offer coverage for:

  • dental
  • vision
  • hearing
  • health perks like fitness memberships

Another option is to add a Medigap plan to your Medicare coverage. Like Medicare Advantage plans, these are offered through private insurance providers and can help provide additional coverage toward coinsurance or deductible costs.

It’s important to note that you can’t have a Medicare Advantage (Part C) plan and a Medigap plan at the same time; you can only choose one or the other.

It’s a good idea to add up all of your set and expected costs before selecting a plan. A Medicare agent can help you better understand your options and anticipated expenses.

Medicare Part A can assist with inpatient care costs, but only for a specific time period.

If you or a family member anticipate an extended hospital stay for an underlying health condition, treatment, or surgery, take a look at your insurance coverage to understand your premiums and to analyze your costs.

Though Medicare provides coverage for some of your hospital stay, you’ll be expected to pay for a portion of the bill.

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