Medicare Plan A is hospital insurance, not doctor visits

Medicare Plan A is the hospital part of Original Medicare. It pays for inpatient hospital stays, skilled nursing facility care after a hospital stay, hospice care, and some home health services. It does not pay for doctor visits, outpatient care, prescription drugs, or routine preventive services — those are covered by Plan B or other parts of Medicare.

Most people age 65 and older get Plan A automatically when they turn 65, even if they have not yet started Social Security. You do not have to do anything to receive it. If you worked for at least 10 years and paid Medicare taxes, or if your spouse did, Plan A costs nothing — no monthly premium. If you do not meet the work requirement, you can still buy Plan A, but it will have a monthly cost.

Plan A is part of Original Medicare, which means you can see any doctor or hospital in the United States that accepts Medicare. You are not limited to a network. However, you will pay out-of-pocket costs when you use services, and those costs can add up quickly during a hospital stay.

Key Takeaways

  • Plan A covers hospital stays, skilled nursing care after hospitalization, hospice, and some home health services, but not doctor office visits or prescriptions.
  • Most people age 65 and older receive Plan A automatically at no monthly cost if they or their spouse paid Medicare taxes for at least 10 years.
  • You will pay a deductible before Plan A starts paying, and you will share costs for each day you stay in the hospital after day 60.
  • Plan A works with Plan B (doctor insurance) to form Original Medicare, and many people add a Medigap or Medicare Advantage plan to reduce out-of-pocket costs.

What Plan A actually pays for during a hospital stay

When you are admitted to a hospital as an inpatient, Plan A covers your room, meals, nursing care, medications, and medical equipment used during your stay. It also covers lab tests, X-rays, and surgery performed in the hospital. The key word is inpatient — you must be formally admitted to a bed, not treated in the emergency room or observation unit and sent home the same day.

Plan A pays differently depending on how long you stay. For days 1 through 60 of a hospital stay in a benefit period, you pay a deductible (the amount changes each year), and Plan A covers the rest. For days 61 through 90, you pay a daily coinsurance amount, and Plan A covers the rest. If you stay longer than 90 days, you can use your lifetime reserve days — Plan A covers most costs, but you pay a higher daily amount. Once your lifetime reserve days run out, you pay all costs.

A benefit period starts the day you enter the hospital and ends 60 days after you leave. If you are readmitted after that 60-day window closes, a new benefit period begins and you pay the deductible again.

Skilled nursing facility care after you leave the hospital

If your doctor determines you need skilled nursing care after a hospital stay — such as physical therapy or wound care — Plan A will pay for up to 100 days in a skilled nursing facility per benefit period. You must have been in the hospital for at least three consecutive days first, and you must be admitted to the facility within 30 days of leaving the hospital.

For days 1 through 20, Plan A covers all costs. For days 21 through 100, you pay a daily coinsurance amount, and Plan A covers the rest. If you stay longer than 100 days, you pay all costs. This benefit is not the same as long-term care or assisted living — it is temporary care while you recover from an acute illness or injury.

Hospice care and home health services

Plan A covers hospice care when your doctor and another doctor agree that you have a terminal illness and six months or less to live. You pay nothing for hospice services related to your terminal condition, though you may pay a small copay for medications and respite care. Hospice focuses on comfort and quality of life rather than curing the illness.

Plan A also covers some home health services — such as skilled nursing care, physical therapy, or occupational therapy — when you are homebound and your doctor orders the care. You pay nothing for home health services covered by Plan A. However, Plan A does not cover custodial care (help with bathing, dressing, or meals) or ongoing information at home — that is not a Medicare benefit.

Out-of-pocket costs you will pay with Plan A alone

Plan A has specific costs you pay before and during care. The hospital deductible changes each year; you pay this once per benefit period before Plan A starts paying. After day 60 of a hospital stay, you pay a daily coinsurance amount for days 61 through 90. If you use lifetime reserve days beyond day 90, you pay a higher daily amount. For skilled nursing care, you pay coinsurance starting on day 21.

These costs can be substantial. A hospital stay longer than 60 days or a skilled nursing stay longer than 20 days will cost you money out of pocket. Many people add a Medigap plan (also called Medigap or supplemental insurance) or switch to a Medicare Advantage plan to reduce these costs. Medigap plans are sold by private insurance companies and help pay the deductibles and coinsurance that Plan A does not cover. Medicare Advantage plans are an alternative to Original Medicare and often include Plan B coverage, prescription drug coverage, and dental or vision benefits in one plan.

How Plan A works with Plan B and other Medicare parts

Plan A is only half of Original Medicare. Plan B is the medical insurance part that covers doctor visits, outpatient surgery, lab tests ordered by your doctor, and preventive care. Plan A and Plan B together form Original Medicare. You need both to have full hospital and doctor coverage under Original Medicare.

If you want prescription drug coverage, you must add Plan D (prescription drug insurance) separately. Plan D is sold by private insurance companies and covers medications your doctor prescribes. You can also add Plan C (vision) or Plan E (dental), though these are not part of Original Medicare.

Alternatively, you can choose a Medicare Advantage plan (also called Plan C) instead of Original Medicare. Medicare Advantage plans are sold by private insurance companies and must include hospital and doctor coverage. Many also include prescription drug coverage, dental, vision, and hearing benefits. However, Medicare Advantage plans typically have networks — you must use doctors and hospitals in the plan's network, or pay more. Original Medicare has no network.

When you first become may be able to access for Plan A

You become may be able to access for Plan A when you turn 65, even if you are still working. You have a seven-month window to sign up: three months before the month you turn 65, the month you turn 65, and three months after. If you sign up during this window, your coverage starts the first day of the month you turn 65.

If you miss this window and do not sign up right away, you may have to pay a late enrollment penalty for as long as you have Medicare. The penalty is a percentage of the Plan A premium and is added to your monthly cost. The only exception is if you were covered by a group health plan through your job or your spouse's job when you turned 65 — in that case, you have eight months after your employment ends or coverage ends to sign up without penalty.

If you are already receiving Social Security when you turn 65, you will be signed up for Plan A automatically. You will receive a Medicare card in the mail. If you are not yet receiving Social Security, you will need to contact Social Security or Medicare to sign up.

Frequently Asked Questions

Do I have to take Plan A if I am still working at 65?

No. If you or your spouse are still working and covered by a group health plan, you can delay Plan A without penalty. Once you or your spouse stop working or lose coverage, you have eight months to sign up. If you wait longer than that, you may pay a late enrollment penalty.

What is the difference between Plan A and Medicare Advantage?

Plan A is part of Original Medicare, which has no network — you can see any doctor or hospital that accepts Medicare. Medicare Advantage is an alternative to Original Medicare sold by private insurance companies and usually includes a network. Medicare Advantage often costs less per month but may have higher out-of-pocket costs when you use care.

Does Plan A cover emergency room visits?

Plan A covers emergency room visits only if you are admitted to the hospital as an inpatient afterward. If you are treated in the emergency room and sent home, Plan B covers that visit, not Plan A. If you are in observation status (not formally admitted), Plan B also covers it.

Can I switch from Plan A to Medicare Advantage later?

Yes. You can switch during the Annual Enrollment Period (October 15 to December 7 each year), and your new coverage starts January 1. You can also switch if you have a may have access to life event, such as moving out of your plan's service area or losing other health coverage.

What happens if I run out of lifetime reserve days?

Once you use all 60 lifetime reserve days, Plan A stops paying for hospital stays beyond day 90. You pay all costs for any additional hospital days. Lifetime reserve days do not renew — they are a one-time benefit for your entire time on Medicare.