Inpatient or Outpatient? It Makes a Difference with Medicare.

I recently received an article from Medicare that explains the difference between being treated in a hospital as an “admitted” patient versus being treated as an “outpatient”.

This article applies to people who use their Medicare card. It does not apply to people enrolled in a Medicare Advantage plan – unless your plan requires you to pay 20% of the cost for “outpatient services”.

The costs mentioned in this article also do not apply to most people who have a Medicare supplement. That’s because most supplements (C, D, F, G, N) will pay the Medicare deductibles and 20% co-insurance.

I decided to add my own notes/comments to the piece to point out how different coverage applies to the points made by David Sayen, Medicare’s Regional Administrator.  The article is in the gray sections.

Your hospital status (whether the hospital classifies you as an inpatient or outpatient) affects how much you pay for hospital services like X-rays, drugs, and lab tests.

It also may affect whether Medicare will cover care you get in a skilled nursing facility.

NOTE: Medicare requires a 3-day stay in a hospital for it to cover skilled nursing facility charges.  Medicare Advantage plans do not have this requirement.

You’re an inpatient starting the day 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, and the doctor hasn’t written an order to admit you to the hospital as an inpatient. 

Note: Many people assume they’ve been “admitted” to the hospital, but this might not be the case. I wrote about this in a recent post about Ralph, who was treated at Northwest Hospital.

In these cases, you’re an outpatient even if you spend the night at the hospital.

Observation services are tests and other outpatient services that 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.

If you’re in the hospital more than a few hours, always ask your doctor or the hospital staff if you’re an inpatient or an outpatient.

What do you pay as an inpatient?

Medicare Part A (Hospital Insurance) covers inpatient services including semi-private room, nursing care, drugs, and meals. Generally, you pay a one-time deductible for all hospital services for the first 60 days you’re in the hospital. The Part A deductible this year is $1,184.

Medicare Part B (Medical Insurance) covers most doctor services when you’re an inpatient. You pay 20% of the Medicare-approved amount for doctor services after paying the Part B deductible ($147 in 2013).

NOTE:  With Medicare Advantage, you have a set co-pay for each day you are in the hospital (generally days 1-5 or 1-6).  Everything done for you during your stay is covered by your Advantage plan, so there should be no additional bills. If you get an odd bill, call your Advantage plan and tell them to fix it.

What do you pay as an outpatient?

Part B also covers outpatient hospital services. Generally, this means you pay a co-payment for each individual outpatient service. The amount may vary by service.

The copayment for a single outpatient hospital service can’t be more than the inpatient hospital deductible. However, your total co-payment for all outpatient services may be more than the inpatient hospital deductible.

Part B 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.

NOTE: Most Medicare Advantage plans have a set co-pay for outpatient services  rather than 20% co-insurance. The set co-pay will depend on the plan and can be $75, $175, $250, or some other amount.  If your Advantage plan has a 20% co-pay for outpatient services, you could get burnt like Ralph in the story I wrote about.

Generally, the 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.

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

Also, keep in mind that Medicare will only cover care you get in a skilled nursing facility if you’ve been a hospital inpatient for at least 3 days in a row (counting the day you were admitted as an inpatient but not counting the day you were discharged).

NOTE:  If you have a Medicare supplement, you still must meet the 3-day hospital inpatient requirement.  Your supplement will only pay its part of skilled nursing facility charges if Medicare pays its part.

If you weren’t an inpatient for 3 days but you still need care after your discharge, ask if you can get home health care or if other programs like Medicaid or veterans benefits will cover skilled nursing for you.

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

For more detailed information on how Medicare covers inpatient and outpatient hospital services, read Medicare’s brochure, “Are You a Hospital Inpatient or Outpatient?” You can find it online

David Sayen is Medicare’s regional administrator for Arizona, California, Hawaii, Nevada, and the Pacific Territories. You can always get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

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One Response to "Inpatient or Outpatient? It Makes a Difference with Medicare."

  1. JEngdahlJ says:

    Medicare Advantage allows individuals to choose from a wide range of competing plans that may offer richer benefits. See:

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