If You Have Medicare – Ask!

Did you know that even if you stay in a hospital overnight, you still might be considered an outpatient? Your status (“inpatient” or “outpatient”) affects how much you pay for hospital services and also may 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 physician'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 physician 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 physician decide if the patient needs to be admitted as an inpatient or can be discharged. Observation services may be provided in the emergency department or in any bed located anywhere in the hospital. The decision for inpatient hospital admission is a complex medical decision based on your physician's judgment and your need for medically necessary hospital care. An inpatient admission is generally appropriate when you’re expected to need two or more midnights of medically necessary hospital care, but your physician must order such admission.

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 physician services when you’re an inpatient. You pay 20 percent of the Medicare-approved amount for physician 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 co-payment for each individual outpatient hospital service. This amount may vary by service. 

Part B also covers most of your physician services when you’re a hospital outpatient. You pay 20 percent of the Medicare-approved amount after you pay the Part B deductible. 

Generally, prescription and over-the-counter drugs you get while in an outpatient status, sometimes called “self-administered drugs,” aren’t covered by Part B. For safety reasons, Lakewood Ranch Medical Center does not 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 need to pay out of pocket for these drugs and submit a claim to your drug plan for a potential 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 physician writes an inpatient admission order) for at least three 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 three-day inpatient hospital stay and you need care after your discharge from a hospital, ask if you can get care in other settings (like home healthcare) or if any other programs (like Medicaid or Veterans’ benefits) can cover your SNF care. Always ask your physician or case manager if Medicare will cover your SNF stay. 

How would hospital observation services affect my SNF coverage?

Your physician may order “observation services” to help decide whether you need to be admitted to a hospital as an inpatient or can be discharged. During the time you’re getting observation services in a hospital, you’re considered an outpatient. This means you can’t count this time toward the three-day inpatient hospital stay needed for Medicare to cover your SNF stay. 

For more information about how Medicare covers care in a SNF, visit Medicare.gov/publications to view the booklet “Medicare Coverage of Skilled Nursing Facility Care.” 

Remember: Any days you spend in a hospital as an outpatient (before you’re formally admitted as an inpatient based on the physician's order) aren’t counted as inpatient days. An inpatient stay begins on the day you’re formally admitted to a hospital with a physician's order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day. 

What kinds of conditions usually require observation care?

Observation services are typically ordered for conditions that can be treated in 48 hours or less, or when the cause for your symptoms has not yet been determined. Some examples are nausea, vomiting, weakness, stomach pain, headache, kidney stones, fever, some breathing problems, and some types of chest pain.

How long can a patient remain in observation?

Typically, a decision is made within 48 hours.

What if my physician decides that my condition requires acute inpatient admission?

Your physician must write an order to convert your observation status to an inpatient admission. This decision must be in agreement with the guidelines established by Medicare for medically necessary hospital care, and there must be an expectation that acute hospital care will be required beyond two or more midnights.

Can I be placed under observation after undergoing an outpatient surgical procedure?

Medicare allows for four to six hours as a recovery period for an outpatient procedure. The intent of outpatient surgery is that you have your surgery and go home the same day. However, if you experience a postoperative complication, your physician may decide to keep you in the hospital under observation for further monitoring that may extend overnight.

What if I desire to spend the night after my outpatient surgery? Will Medicare cover this?

No, Medicare will only pay if there is a medical condition that warrants postoperative monitoring. If you were to stay over for patient/family convenience, it would be subject to bed availability, and you would be fully responsible for payment.