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 Medicareapproved
amount after you pay the Part B
deductible.
• Generally, prescription and over-thecounter
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.
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 writes 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
Medicare Status