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20 Medicare-Outpatient or Inpatient? 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 the patient needs 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 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. 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 individual 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 “selfadministered 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. 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 22 Medicare Status Information


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