Medicare — Are you an in-patient or an out-patient?
If you stay overnight in the hospital, your costs and coverage will depend on whether you have inpatient status or outpatient status in the hospital. Staying overnight in the hospital does not make you a hospital inpatient. You only become an inpatient after your doctor formally admits you to the hospital.
In general, doctors will only admit you if they expect you will need to stay at least two days overnight in the hospital. Part A covers most of your care when you have inpatient.
However, when you are in the emergency room or in the hospital under observation, you are usually an outpatient. You may be under observation if your doctor is keeping an eye on you to decide whether or not to admit you. Observation services may look and feel exactly like inpatient services. Observation can last just a few hours or longer. Part B covers your care, including observation services, when you have outpatient.
Whether your care gets covered under Part A or Part B makes a difference. You will likely pay more for care if it’s considered outpatient rather than inpatient. It also effects whether you may qualify for Medicare to pay for your stay in a skilled nursing facility (SNF) after you leave the hospital. See below for more information.
Your patient status can change during your stay. Ask if you are an inpatient or outpatient repeatedly. If you are unable to ask this yourself, your family members and caregivers can ask for you.
Read below to learn about your costs for hospital care as an inpatient or outpatient. The costs discussed below apply to those with Original Medicare. If you have a Medicare Advantage Plan, your costs in the hospital may be different. Contact your plan for information about what you pay for an inpatient or outpatient hospital stay.
Costs for inpatient hospital care
When you are admitted to a hospital as an inpatient, you pay a one-time deductible for most hospital care provided and then have no co-payments for the first 60 days. (In 2016 the hospital deductible is $1288.) Medicare Part A covers nurse’s services, medically necessary medications, X-rays, supplies, appliances, and equipment the hospital provides for you to use during your inpatient hospital stay. Medicare Part B covers doctors’ services you receive in the hospital. You usually owe a separate 20 percent coinsurance for these doctors’ services.
Your status as a hospital inpatient may qualify you for Medicare to pay for a Skilled Nursing Facility (SNF) stay if you need it after you leave the hospital. In order to qualify for a Medicare-covered SNF stay, you must have been a hospital inpatient for at least three days and meet other requirements. The day you become an inpatient counts toward the qualifying days; the day the hospital discharges you does not count toward the qualifying days.
Costs and coverage for outpatient hospital care
If you are an outpatient during your hospital stay, Medicare Part B covers most of your services. You typically pay a coinsurance for each medical service you receive in the hospital after you meet the Part B deductible. For example, you will have separate charges for emergency room care, observation care, x-rays and lab tests. You must also pay the coinsurance for physician services you receive. Physician services include any time you spent with a physician while you were in the hospital, even if that physician was not your primary doctor or surgeon. Original Medicare Part B generally covers 80 percent of the cost of most services you receive after you have met your yearly deductible. In most cases, you are responsible for paying the remaining 20 percent coinsurance.
When Part B covers your hospital care, you may have higher costs than if Part A covers your stay.
You may have multiple coinsurances. Each individual copayment must be less than the Part A deductible ($1,288 in 2016). However, if you add up the coinsurances for each ser vice the total could be higher than the Part A deductible. Part B will not cover the cost of your prescription medications that you routinely take. You will need to get them covered by Part D. If the hospital pharmacy is not in your Part D plan’s network, you typically have higher out of pocket costs than you would at an innetwork pharmacy.
You will need to pay the hospital for these medications and then send the bill to your Part D to pay its share of the costs. The days spent as an outpatient do not qualify you for a SNF stay. As a result, you will need to pay the full cost your SNF stay. Medicare Part B may pay for certain skilled services (like physical therapy) you receive while staying in the SNF.
Mike Zimmer is president of Bay State Insurance Agency Ltd. in Centreville. He may be reached at 410-758-1680.