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What Does Inpatient Versus Outpatient Mean for Medicare?


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If you’re covered under Original Medicare (Part A and Part B), the inpatient definition versus outpatient definition actually determines how much you may pay out of pocket for your health care. This article helps you understand what is outpatient and what inpatient care is so you know what to expect when the hospital bill arrives.

What is the inpatient definition?

Very simply, the inpatient definition is a person who has been formally admitted to a hospital floor under written orders from a treating doctor. If you go to the emergency room for chest pain, you are still not an inpatient, even if you get lab tests, x-rays, or prescription drug treatment. If you are sent to the ICU for intensive short-term monitoring of your chest pain, you still might not meet the inpatient definition, unless your doctor writes orders to admit you to the floor for additional treatment.

What is the outpatient definition?

You meet the outpatient definition any time you get care in an outpatient department or free-standing ambulatory surgery center, even if you are kept overnight. You only become an inpatient if your doctor writes orders for you to be admitted to the hospital.

Here are some situations where the inpatient definition versus outpatient definition can be a bit confusing:

  • You have an outpatient procedure or surgery and your doctor decides to keep you overnight to monitor your vital signs. In this situation, you’re still under the outpatient definition.
  • You visit the emergency room for dizziness and your doctor sends you to an observation unit for additional monitoring overnight. Again, you probably still meet the outpatient definition even though you may have been moved from the emergency department to an observation unit.

What is outpatient Medicare coverage?

If you meet the outpatient definition, you are typically covered under Medicare Part B. Under Medicare Part B, all medically necessary visits by a health care provider, laboratory and diagnostic imaging tests and procedures are covered at 80% of the allowable charges. You typically pay 20% after you meet your Part B deductible.

In some cases, you may pay a flat copayment amount for certain outpatient services and procedures.

If you meet the outpatient definition, your time in the hospital or outpatient department doesn’t count toward your hospitalization requirements for admission to a skilled nursing facility. In order to qualify for Medicare coverage of skilled nursing home care, you must have three days of inpatient hospitalization prior to transfer.

What is inpatient Medicare coverage?

When you are admitted to the hospital under a doctor’s orders, you are considered an inpatient. Medicare Part A covers all medically necessary inpatient care. You have no coinsurance amount if your stay is under 60 days, although you must pay your Part A deductible. If your stay goes beyond 60 days, you have a daily coinsurance amount from day 61 through 90. For days 91 and beyond you have an even higher coinsurance for each “lifetime reserve day.” A lifetime reserve day is an additional day that Medicare will pay for hospital care over 90 days. You have a total of 60 lifetime reserve days in your lifetime. When your lifetime reserve days are used up, you pay all costs.

Your last day of inpatient care is considered the day before you are discharged home or to another facility. For example, if you go to the emergency room on Monday and your doctor keeps you under observation until Tuesday and then admits you to the telemetry unit, you meet the inpatient definition as of Tuesday, not Monday.

Under the same example, if you are discharged Friday morning, your last full day as an inpatient is actually Thursday. Under this situation, your total inpatient stay is three days (Tuesday, Wednesday, and Thursday), even though you were technically “at” the hospital for five days. Medicare Part B would generally cover your care Monday and Tuesday, until you arrive on the floor with doctor’s orders, and Medicare Part A would typically cover your care on the telemetry unit.

Do you want to find a Medicare plan that can cover you as both an inpatient and outpatient? Just enter your zip code on this page to begin looking.

 

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