SOCIAL INSURANCE · 6 MIN READ

Medicare Part A and Part B Benefits and Cost Sharing

Part A is hospital insurance, and its coverage is organized around the benefit period. A benefit period begins on inpatient admission and ends only after the beneficiary has gone 60 consecutive days without inpatient hospital or skilled nursing care; there is no limit on the number of benefit periods, but the Part A deductible applies once per benefit period, not per year. Within a benefit period, days 1-60 of inpatient care are fully covered after the deductible; days 61-90 carry a daily coinsurance; and beyond day 90 the beneficiary may draw on a once-in-a-lifetime pool of 60 lifetime reserve days at a higher daily coinsurance. Skilled nursing facility (SNF) coverage requires a qualifying inpatient hospital stay of at least 3 consecutive days, admission to the SNF within 30 days of discharge, and a daily skilled need; Part A then covers up to 100 days per benefit period — days 1-20 in full, days 21-100 with daily coinsurance. Observation status does not count toward the 3-day inpatient requirement, a costly billing distinction. Part A also houses the hospice benefit. Election requires written certification by the hospice medical director and the attending physician that life expectancy is 6 months or less if the illness runs its normal course; the benefit is structured as two 90-day periods followed by unlimited 60-day periods with recertification. Electing hospice waives curative treatment for the terminal condition, but the patient may revoke the election at any time and return to regular Medicare. Home health coverage separately requires that the beneficiary be homebound. Part B is medical insurance, funded by premiums plus general revenue. After a single annual deductible, Part B pays 80% of the Medicare-approved amount and the beneficiary owes 20% coinsurance. Non-participating providers who do not accept assignment may bill above the approved amount, but never more than the 115% limiting charge; the gap is the excess charge, which only certain Medigap plans cover. Under the ACA, preventive services rated A or B by the U.S. Preventive Services Task Force cost the beneficiary $0 — no deductible, no coinsurance — including the Welcome to Medicare visit (first 12 months of Part B) and the Annual Wellness Visit, which becomes available after the first 12 months of enrollment.