Inpatient or outpatient hospital status affects your costs
Your hospital status—whether you're an inpatient or an outpatient—affects how much you pay for hospital services (like X-rays, drugs, and lab tests). Your hospital status may also affect whether Medicare will cover care you get in a skilled nursing facility (SNF) following your hospital stay.
- You're an inpatient starting when you're formally admitted to the hospital with a doctor's order. The day before you're discharged is your last inpatient day.
- You're an outpatient if you're getting emergency department services, observation services, outpatient surgery, lab tests, or X-rays, or any other hospital services, and the doctor hasn't written an order to admit you to a hospital as an inpatient. In these cases, you're an outpatient even if you spend the night in the hospital.
The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care. An inpatient admission is generally appropriate when you’re expected to need 2 or more midnights of medically necessary hospital care. But, your doctor must order such admission and the hospital must formally admit you in order for you to become an inpatient.
What are my appeal rights if I was admitted to the hospital as an inpatient on or after January 1, 2009 and the hospital changed my status from “inpatient” to “outpatient getting observation services?”
Each day you have to stay, you or your caregiver should ask the hospital and/or your doctor, a hospital social worker, or a patient advocate if you’re an inpatient or outpatient.
How will Medicare pay in common hospital situations?
Remember, you pay your deductible , coinsurance, and copayment . The copayment for a single outpatient hospital service can’t be more than the inpatient hospital deductible. However, your total copayment for all outpatient services may be more than the inpatient hospital deductible.
| Situation | Inpatient or outpatient | Part A pays | Part B pays |
|---|---|---|---|
| You're in the Emergency Department (also known as the Emergency Room or "ER") and then you're formally admitted to the hospital with a doctor's order. | Outpatient until you’re formally admitted as an inpatient based on your doctor’s order. Inpatient after your admission. | Your inpatient hospital stay and, for most hospitals, all related outpatient services provided during the 3 days before your admission date. | Your doctor services |
| You come to the ER with chest pain, and the hospital keeps you for 2 nights. One night is spent in observation and the doctor writes an order for inpatient admission on the second day. | Outpatient until you’re formally admitted as an inpatient based on your doctor’s order. Inpatient after your admission. | Your inpatient hospital stay and for most hospitals, all related outpatient services provided during the 3 days before your admission date. | Your doctor services |
| You go to a hospital for outpatient surgery, but they keep you overnight for high blood pressure. Your doctor doesn't write an order to admit you as an inpatient. You go home the next day. | Outpatient | Nothing | Your doctor services and hospital outpatient services (for example, surgery, lab tests, or intravenous medicines) |
| Your doctor writes an order for you to be admitted as an inpatient, and prior to discharge the hospital changes your status to outpatient. Your doctor must agree, and the hospital must tell you in writing—while you're still a hospital patient before you're discharged—that your hospital status changed from inpatient to outpatient. | Outpatient | Nothing | Your doctor services and hospital outpatient services |