What Does Inpatient Versus Outpatient Mean for Medicare?

Last Updated : 06/12/20194 min read

Many people may think that staying overnight at the hospital automatically means they’re inpatients. But the distinction between inpatient vs. outpatient isn’t as simple as you might think.

Learn the difference between inpatient vs. outpatient and how this hospital status may affect your Medicare costs and coverage.

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Inpatient vs. outpatient: what’s the difference?

According to the Centers for Medicare & Medicaid Services (CMS), here’s how Medicare decides inpatient versus outpatient status:

  • Inpatient: this status starts the day your doctor writes a formal order to admit you to the hospital.
  • Outpatient: this status applies when you’re getting services or tests (whether they be outpatient procedures or urgent care services) and the doctor hasn’t written an order to formally admit you as inpatient.

It’s important to note that just because you’re staying overnight in the hospital does not automatically mean you’re an inpatient.

For example, a doctor may decide to put you on “observation” before deciding whether to admit you as an inpatient or discharge you. If you’re under observation, you’re still an outpatient, even if you stay overnight at the hospital.

Also note that whether you’re inpatient versus outpatient isn’t about the types of procedures or tests you’re getting, which may overlap between the two statuses. If you’re not sure if you have inpatient vs. outpatient status, be sure to clarify with your doctor.

Inpatient vs. outpatient: how this affects costs

To put it simply, the costs you pay can be very different depending on whether you’re an inpatient vs. outpatient.

As an inpatient, you’re generally covered under Medicare Part A:

  • You’ll pay a deductible for each benefit period and $0 coinsurance for the first 60 days.

As an outpatient, you may be covered under Medicare Part B and owe:

  • The Part B annual deductible (if you haven’t already paid it).
  • A copayment or coinsurance amount for each covered hospital outpatient service.
  • A 20% coinsurance for doctor services.

Please note that Part B usually only covers medications you can’t give yourself, such as infusion drugs. Hospitals might not let you bring prescription drugs with you if you’re a hospital outpatient. However, if you have Medicare prescription drug coverage, it may cover self-administered prescription drugs in an outpatient setting. You may need to pay out of pocket first and submit a claim to your Medicare plan afterwards.

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Inpatient vs. outpatient: eligibility for skilled nursing facility coverage

Whether you’re admitted as an inpatient vs. outpatient also affects your coverage for skilled nursing facility services. This is helpful to know should you need them after your hospital stay.

Along with other criteria, Medicare may cover skilled nursing care if you have a qualifying hospital stay. This qualifying hospital stay has to be of at least 3 consecutive inpatient days, not including the day you were discharged. You must also enter the nursing facility within 30 days of being discharged. Importantly, any time in the hospital as an outpatient doesn’t count towards the 3-day inpatient requirement.

Inpatient vs. outpatient: how this decision is made

According to Medicare.gov, being given an inpatient versus outpatient status is usually determined by your doctor’s medical judgment of your health and whether inpatient hospital care is medically necessary.

Typically, a doctor will order that you be admitted as an inpatient if he determines that you need two or more nights of medically necessary hospital services. However, your hospital status as inpatient vs. outpatient is ultimately still based on the doctor’s determination and requires a formal order admitting you as an inpatient.

Inpatient vs. outpatient: how Medicare Advantage coverage works

Medicare Advantage plans cover everything that Medicare Part A and Part B cover, except hospice care, which is still covered under Part A. Please note that Medicare Advantage plans vary when it comes to costs for inpatient vs. outpatient coverage. You’ll need to check with the specific plan for more details. The Evidence of Coverage document is a good place to start.

Hopefully, you now have a clearer picture of why the inpatient vs. outpatient distinction matters. If you’d like to explore Medicare plan options, you can do that easily from the convenience of your computer, tablet, or phone. Just enter your zip code on this page to get started.

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