Just when you thought you understood Medicare!

Posted on May 6, 2012

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Are You a Hospital Inpatient or Outpatient?

If You Have Medicare – Ask!

Did you know that even if you stay in the 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).

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. 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 (ED) 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.

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), 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 the 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?

• Medicare 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, 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. 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 likely will need to pay outof-pocket for these drugs and submit a claim to your drug plan for a refund.

Call your plan for more information.

For more detailed information on how Medicare covers hospital services, including premiums, deductibles, and copayments, visit www.medicare.gov/publications to view the “Medicare & You” handbook.

You can also call 1-800-MEDICARE (1-800-633-4227).

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