Your hospital status—whether you’re an inpatient or an 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 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, 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 in the hospital.
Observation services are hospital outpatient services you get while your doctor decides whether to admit you as an inpatient or discharge you. You can get observation services 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.
Here are some common hospital situations and a description of how Medicare will pay. Remember, you pay your deductible, coinsurance, and copayment.
| Situation | Inpatient or outpatient | Part A pays | Part B pays |
|---|---|---|---|
| You’re in the Emergency Department (ED) (also known as the Emergency Room or “ER”) and then you’re formally admitted to the hospital with a doctor’s order. | Outpatient until you’re formally admitted as an inpatient based on your doctor’s order. Inpatient following such admission. | Your inpatient hospital stay | Your doctor services |
| You visit the ED and are sent to the intensive care unit (ICU) for close monitoring. Your doctor expects you to be sent home the next morning unless your condition worsens. Your condition resolves and you’re sent home the next day. | Outpatient | Nothing | Your doctor services |
| You come to the ED with chest pain, and the hospital keeps you for 2 nights. One night is spent in observation and the doctor writes an order for inpatient admission on the second day. | Outpatient until you’re formally admitted as an inpatient based on your doctor’s order. Inpatient following such admission. | Your inpatient hospital stay | Doctor services and hospital outpatient services (for example, ED visit, observation services, lab tests, or EKGs) |
| You go to a hospital for outpatient surgery, but they keep you overnight for high blood pressure. Your doctor doesn’t write an order to admit you as an inpatient. You go home the next day. | Outpatient | Nothing | Doctor services and hospital outpatient services (for example, surgery, lab tests, or intravenous medicines) |
| Your doctor writes an order for you to be admitted as an inpatient, and the hospital later tells you it’s changing your hospital status to outpatient. Your doctor must agree, and the hospital must tell you in writing—while you’re still a hospital patient before you’re discharged—that your hospital status changed. | Outpatient | Nothing | Doctor services and hospital outpatient services |
Remember, even if you stay overnight in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital.
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.
Source: Medicare.gov