Revised August 2018

Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!

Did you know that even if you stay in a hospital overnight, you might still be considered an “outpatient?” Your hospital status (whether the hospital considers you an “inpatient” or “outpatient”) affects how much you pay for hospital services (like X-rays, drugs, and lab tests) and 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 a 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, 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 at the hospital.

Note: Observation services are hospital outpatient services given to help the doctor decide if you need to be admitted as an inpatient or can be discharged. Observation services may be given in the emergency department or another area of 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 for payment under Medicare Part A when you’re expected to need 2 or more midnights of medically necessary hospital care, but your doctor must order this admission and the hospital must formally admit you for you to become an inpatient.

Read on to understand the differences in Original Medicare coverage for hospital inpatients and outpatients, and how these rules apply to some common situations. If you have a Medicare Advantage Plan (like an HMO or PPO), your costs and coverage may be different. Check with your plan.

What do I pay as an inpatient?

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

Part B covers outpatient hospital services. Generally, this means you pay a copayment for each outpatient hospital service. This amount may vary by service.

Note: 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.

Part B also covers most of your doctor services when you’re a hospital outpatient. You pay 20% of the Medicare-approved amount after you pay the Part B deductible.

Generally, 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. Also, for safety reasons, many hospitals have policies that don’t allow patients to bring prescription or other drugs from home. If you have Medicare prescription drug coverage (Part D), these drugs may be covered under certain circumstances. You’ll likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Call your drug plan for more information

For more detailed information on how Medicare covers hospital services, including premiums, deductibles, and copayments, visit Medicare.gov. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Here are some common hospital situations and a description of how Medicare will pay. Remember, you pay deductibles, coinsurance, and copayments.

Situation

You’re in the emergency department (ED) (also known as the emergency room or “ER”) and then you’re formally admitted to the hospital with a doctor’s order.

Inpatient or outpatient

Outpatient until you’re formally admitted as an inpatient based on your doctor’s order.

Inpatient after your admission.

Part A pays

Your inpatient hospital stay and all related outpatient services provided during the 3 days before your admission date.

Part B pays

Your doctor services

Situation

You come to the ED 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.

Inpatient or outpatient

Outpatient until you’re formally admitted as an inpatient based on your doctor’s order. Inpatient after your admission.

Part A pays

Your inpatient hospital stay and all related outpatient services provided during the 3 days before your admission date.

Part B pays

Your doctor services

Situation

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.

Inpatient or outpatient

Outpatient

Part A pays

Nothing

Part B pays

Doctor services and hospital outpatient services (for example, surgery, lab tests, or intravenous medicines)

Situation

Your doctor writes an order for you to be admitted as an inpatient, and the hospital later tells you it’s changing your hospital 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.

Inpatient or outpatient

Outpatient

Part A pays

Nothing

Part B pays

Doctor services and hospital outpatient services

Remember: Even if you stay overnight in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital.

How would my hospital status affect the way Medicare covers my care in a skilled nursing facility (SNF)?

Medicare will only cover care you get in a SNF if you first have a “qualifying inpatient hospital stay.”

A qualifying inpatient hospital stay means you’ve been a hospital inpatient (you were formally admitted to the hospital after your doctor wrote an inpatient admission order) 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).

If you don’t have a 3-day inpatient hospital stay and you need care after your discharge from a hospital, ask if you can get care in other settings (like home health care) or if any other programs (like Medicaid or Veterans’ benefits) can cover your SNF care. Always ask your doctor or hospital staff if Medicare will cover your SNF stay.

How would hospital observation services affect my SNF coverage?

Your doctor may order “observation services” to help decide whether you need to be admitted to a hospital as an inpatient or can be discharged. During the time you’re getting observation services in a hospital, you’re considered an outpatient. This means Medicare won’t count this time towards the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay.

If you have a Medicare Advantage Plan (like an HMO or PPO), your costs and coverage may be different. Check with your plan.

For more information about how Medicare covers care in a SNF, visit Medicare.gov to view the booklet “Medicare Coverage of Skilled Nursing Facility Care.”

Here are some common hospital situations that may affect your SNF coverage:

Situation

You came to the ED and were formally admitted to the hospital with a doctor’s order and spent 3 days in the hospital as an inpatient after admission. You were discharged on the 4th day.

Is my SNF stay covered?

Yes, if all other coverage requirements are met. You met the 3-day inpatient hospital stay requirement for a covered SNF stay

Situation

You came to the ED and spent one day getting observation services. Then, you were formally admitted to the hospital as an inpatient for 2 more days.

Is my SNF stay covered?

No. Even though you spent 3 days in the hospital, you were considered an outpatient while getting ED and observation services. These days don’t count toward the 3-day inpatient hospital stay requirement.

Remember: Any days you spend in a hospital as an outpatient (before you’re formally admitted as an inpatient based on the doctor’s order) aren’t counted as inpatient days. An inpatient stay begins on the day you’re formally admitted to a hospital as an inpatient with a doctor’s order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day

What are my rights?

No matter what type of Medicare coverage you have, you have certain guaranteed rights. As a person with Medicare, you have the right to all of these:

Have your questions about Medicare answered.

Learn about all of your treatment choices and participate in treatment decisions.

Get a decision about health care payment or services, or prescription drug coverage.

Get a review of (appeal) certain decisions about health care payment, coverage of services, or prescription drug coverage.

File complaints (sometimes called “grievances”), including complaints about the quality of your care.

For more information about your rights, the different levels of appeals, and Medicare notices, visit Medicare.gov to view the booklet “Medicare Rights & Protections.” You can also call 1-800-MEDICARE (1-800-633-4227). (TTY: 1-877-486-2048).

Where can I get more help?

If you need help understanding your hospital status, talk to your doctor or someone from the hospital’s utilization or discharge planning department.

For more information on Part A and Part B coverage, read your “Medicare & You” handbook, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). (TTY: 1-877-486-2048).

For more information about coverage of self-administered drugs, visit Medicare.gov to view the publication “How Medicare Covers Self-administered Drugs Given in Hospital Outpatient Settings”, or call 1-800-MEDICARE.

To ask questions or report complaints about the quality of care of a Medicare-covered service, call your Quality Improvement Organization (QIO). Visit Medicare.gov, or call 1-800-MEDICARE to get the phone number.

To ask questions or report complaints about your care in a nursing home, call your State Survey Agency. Visit Medicare.gov with a link to Medicare.gov/NursingHomeCompare/Resources/State-Websites.html, or call 1-800-MEDICARE to get the phone number

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/nondiscrimination/ accessibility-nondiscrimination.html, or call 1-800-MEDICARE (1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

Paid for by the Department of Health & Human Services.

CMS Product No. 11435