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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
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Medicare Status Information