Inpatient or Outpatient?

If you have Medicare, please be aware of your hospital status by asking staff if you considered an inpatient or an outpatient. Even if you stay in the hospital overnight, you may still be considered an outpatient. Your hospital status affects how much you pay for hospital services and whether Medicare covers skilled nursing facility care. If you have a Medicare Advantage Plan (like HMO or PPO) costs and coverage may be different, so please refer to your plan.

Inpatient Status
An inpatient admission begins the day you’re formally admitted to the hospital with a doctor’s order. The day before you’re discharged is your last inpatient day.

Outpatient Status
You are considered an outpatient if you are receiving emergency department services, observation services, lab tests, or x-rays. The doctor hasn’t written an order to admit you as an inpatient, even if you spend the night at the hospital.

What do I pay as an inpatient?
Medicare Part A (Hospital Insurance) covers inpatient hospital service. Generally, this means you pay a one-time deductible for all of your hospital services for the first 60 days you’re in the hospital.

Medicare Part B (Medical Insurance) covers most of your doctor services when you’re an inpatient. You pay 20% of the Medicare-approved amount for doctor services after paying the Part B deductible.

What do I pay as an outpatient?
Medicare Part B covers outpatient hospital and doctor services. Generally, this means you pay a copayment for each individual outpatient hospital service. This amount may vary by service.
The copayment amount for a single outpatient hospital service can’t be more than the inpatient hospital deductible. In some cases, your total copayment for all services may be more than the inpatient hospital deductible. Part B also covers most of your doctor services when you’re a hospital outpatient. You pay 20% of the Medicare-approved amount after the Part B deductible.

Generally, the prescription and over-the-counter drugs you get in an outpatient setting like an emergency department (sometimes called “self-administered drugs”) aren’t covered by Part B. If you have Medicare Part D prescription drug coverage, these drugs may be covered under certain circumstances. You will likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Call your plan for more information.

How would my hospital status affect the way that Medicare covers care in a skilled nursing facility?
Medicare will only cover your care in a Skilled Nursing Facility if you first have a “qualifying hospital stay.” A qualifying hospital stay means you’ve been a hospital inpatient for at least 3 days in a row (counting the day you were admitted as an inpatient, but not counting the day of your discharge). Remember, an inpatient admission begins the day you’re formally admitted to the hospital with a doctor’s order. That date is your first inpatient day and begins at midnight. The day you are discharged doesn’t count as an inpatient day.