For those with Medicare, hospital coverage is a crucial factor to consider when making healthcare decisions. While you may not foresee the need to stay in the hospital, knowing what your Medicare coverage includes and how long it will last if needed is essential.
This article will cover the standard length of your stay in the hospital under Medicare, along with options for long-term care. We will also share information on what is and is not covered by Medicare during a hospital stay. Then we will discuss the differences between Medigap and a Medicare Advantage plan.
Hospital Stays and Seniors
As you get older, you’re more likely (twice as likely, in fact) to need to stay at the hospital at some point compared to your middle age counterparts. Many Americans over 65 are hospitalized at some point during the year and stay for an average of five days.
While you may be in good health today, this is a sobering fact that you must consider as you plan out your likely healthcare needs and costs.
What Does Original Medicare Cover?
Medicare Part A (Hospital Insurance) covers inpatient hospital care if you:
- are admitted after an official doctor’s order; and
- the hospital accepts Medicare.
In some instances, Medicare will also cover your stay if the hospital’s Utilization Review Committee approves it while you are admitted. You can receive care in acute care hospitals, long-term care hospitals, inpatient rehabilitation or psychiatric facilities, and critical access hospitals.
The key word here is inpatient hospital care. You must understand whether you are an inpatient or an outpatient because your coverage will differ. For example, if you get an X-ray as an outpatient, you pay 20% (after meeting the Part B deductible). If you are an inpatient, you pay a separate hospital facility co-pay.
You may think, “If I am staying at the hospital, I must be an inpatient.” However, that is not necessarily true. Your benefit period starts when a doctor formally orders you to be admitted, and the hospital admits you.
Let’s review a few common scenarios.
You arrive at the Emergency room, and the doctor has you formally admitted as an inpatient. You are an inpatient for your entire stay and will be covered.
You go to the hospital for day surgery but are kept overnight for observation. You leave the next day, and the doctor does not formally admit you. Despite staying overnight, you are an outpatient and will be responsible for the cost of your stay in the hospital under Medicare.
You go to the emergency room and are kept for two days. Before the second day, the doctor writes an order for inpatient admission. You are an inpatient. Therefore your inpatient stay and any outpatient treatment for up to three days prior is covered.
Medicare Part B will also generally cover 80% of the doctor services you receive during your stay.
What Will You Pay for Your Stay Hospital Under Medicare?
You may be wondering, “How long will Medicare pay for my hospital stay?”
For 2023, you will first have to pay a $1,600 deductible for each benefit period. The payments are then as follows:
- Days 1–60: $0 coinsurance
- Days 61–90: $400 coinsurance per day
- Day 91 until the 60 lifetime reserve days* have been used: $800 coinsurance per day
- Any other days: you are responsible for the full cost of your care
*Lifetime reserve days are 60 days you can use at any point over your lifetime. After that, you will be responsible for all your inpatient hospital costs.
Please also note that inpatient mental health care has a lifetime cap of 190 days.
Medicare covers inpatient hospital services, including semi-private rooms, meals, general nursing, and drugs, amongst other items. Medicare does not cover private-duty nursing, private rooms, or personal care items.
When it comes to long-term care hospitals, a note about deductibles: you do not need to pay a deductible for your stay at a long-term care hospital if you already paid a deductible for a previous hospitalization.
You would not need to pay a deductible if, for example, you were transferred directly from an acute care hospital or admitted to a long-term care hospital within 60 days of being discharged from another hospital.
Supplemental (Medigap) Versus Medicare Advantage Plans
So how do you approach the costs not covered by Original Medicare? You can cover those costs with a supplement plan (like Medigap) or a Medicare Advantage plan.
With Medigap, you will generally not have any out-of-pocket costs for inpatient hospital services. Medigap will typically pay for services at any hospital that accepts Medicare. While it is more expensive, this can be very handy for those who spend part of the year living in a different state, for example. However, unlike Medicare, Medigap does not cover dental or vision costs.
Medicare Advantage plans usually charge a daily co-pay for inpatient hospital services, which is typically around $300 for the first six days of your stay. After that, the amount you will be required to pay varies depending on the plan. Medicare Advantage plans tend to have a narrow network of approved healthcare providers and hospitals, which can be an issue if, for instance, you live in a rural or relatively isolated area.
Choosing the Right Plan for You
It is so vital that you choose the right plan for your family and your health needs. Suppose you enroll in a Medicare Advantage Plan and realize it doesn’t meet your needs. In that case, you can switch to a Medigap or another Medicare Advantage plan, but only during the annual open enrollment period.
Be sure to research your health insurance options and make an informed decision on the best coverage for you. At The Medicare Family, we guide you through that process. No two people are alike, and no two plans are, either.
We’ll help you find the plan that suits your needs best so you can rest assured knowing you have peace of mind and a secure future. Contact us any time to learn more about hospital coverage with Original Medicare, Medigap plans, or Medicare Advantage plans. We look forward to hearing from you!