Medicare Outpatient VS Inpatient (& Why Its Important)

When you go to the hospital in an emergency situation, the last thing on your mind is probably your patient status. But whether you are classified as an “outpatient” or as an “inpatient” can make a huge difference in what you are expected to pay for your visit, especially as a Medicare beneficiary, since it will determine whether Part A or Part B will help pay the costs. Knowing the rules of these classifications, though, can help you to avoid getting a large and unexpected bill in the mail.  

Outpatient Status Explained

x-ray of a person's head
You might go to the hospital and get an X-ray or MRI and be considered an outpatient.

In some cases, you might go to the emergency room, get lab tests, an X-ray, MRI, or other procedures, but not get admitted to the hospital. If this happens, you will be considered an outpatient, or as an observation stay. You can be considered an outpatient even if you stay overnight at the hospital; for example, if you have an outpatient procedure and are kept overnight to be monitored, you are still under outpatient care, unless you are admitted under a doctor’s orders. 

Outpatient Medicare Coverage

Medicare Part B will pay for any medical care that is performed under outpatient status, including diagnostic imaging tests, emergency room visits, medical observation, outpatient surgery, lab tests, x-rays, and colonoscopies. Remember, though, that Medicare Part B will only cover 80% of the cost of these qualified expenses, leaving you to pay your 20% coinsurance after meeting your Part B deductible. 

Inpatient Status Explained

person's hand with wires all around it
If you are admitted to the hospital, then you are considered an inpatient.

After getting assessed as an outpatient at the hospital, you could get admitted to the hospital under a doctor’s order – then, and only then, will your status change to that of an inpatient. Any care you continue to get after this will be considered on an inpatient basis until you are discharged. 

Inpatient Medicare Coverage

Medicare Part A completely covers any medical care that is on an inpatient basis, so you will not have to pay any coinsurance (as long as your stay is under 60 days). The only thing you will be responsible for is your Medicare Part A deductible and a daily coinsurance if your hospital stay goes beyond 60 days. In addition, if your stay lasts longer than 90 days, you will have an even higher coinsurance to pay.

Skilled Nursing Facility Coverage

These two classifications can become confusing, and even problematic, if you get transferred to a skilled nursing facility directly from the hospital. If you are still considered an outpatient, or under an observation stay, when you are transferred, Medicare will not cover your stay at the facility. In order for Medicare to cover a stay at a skilled nursing facility, you will have to be admitted to the hospital and considered an inpatient for 3 days prior to the transfer. house outline with silhouette of two people inside of it with canes This is where knowing your status can make all the difference in what care gets covered, and what care you will be responsible for paying for. If you are being transferred to a skilled nursing facility, be sure to ask how you have been classified; you can ask to have your status changed from outpatient to inpatient, but you have to do so while still in the hospital. Once you are transferred without having been an inpatient for 3 days, you will be left with a bill for the skilled nursing facility stay.  

How to Save on Medical Expenses

If you’d like to save money on your medical expenses, the best way to do so is by considering a Medicare Supplement Plan. Part A might cover inpatient hospital care almost completely, but you’ll probably find that you’ll end up using Medicare Part B far more, since it covers most everyday and outpatient services – and Part B only covers 80% of medical expenses! That remaining 20% can really add up, but a Medicare Supplement Plan can help cover these costs. Each plan offers different coverage at different price points, so you’re sure to find one that meets your individual needs. Not sure where to begin? EZ can compare the 10 different Medicare Supplement Plans and provide you with quotes as well as guidance as to which will provide you the most coverage with the most savings. To get free quotes, simply enter your zip code in the bar above, or to speak to a licensed agent, call 888-753-7207. No obligation.

What Medicare Covers After A Stroke

According to the National Institute of Neurological Disorders and Stroke, over half a million people over the age of 65 suffer from a stroke every year. A stroke can be very serious, and can have long lasting effects on balance, hearing, and vision. It can also cause decreased mobility or even paralysis. Recovery after a stroke can be a long and difficult process, especially if you don’t have the proper insurance coverage. Thankfully, Medicare covers a lot of the aftercare related to recovery from a stroke, including both inpatient and outpatient care, as well as some medical equipment. There are gaps, however, which can be filled by a Medicare Supplement Plan.

illustration of skeletal with the brain colored in red.

Medicare Part A Coverage

If you suffer a stroke, you might need to go to an Inpatient Rehab Facility afterwards to recover and get the therapy that you need. As long as your doctor deems your stay medically necessary, Medicare Part A will cover this inpatient rehabilitation. Medicare will cover the cost of treatment in an inpatient facility for a limited time; if you need to stay longer than 60 days you will have to pay $352 per day for days 61-90. For days 91 and beyond, you will pay $704 in coinsurance per “lifetime reserve day.” You have 60 reserve days over your whole lifetime; after that, you will need to pay the full cost of your stay. 

Medicare Part B Coverage

Medicare Part B will cover any outpatient rehabilitation needed, such as physical therapy, at 80%. You will be responsible for the other 20% coinsurance. As with any service, your doctor must deem your rehab medically necessary in order for it to be covered. If there is any durable medical equipment that is medically necessary, then Part B will also cover the cost of that at 80%. This includes equipment such as wheelchairs, walkers, or canes. Any of this equipment will need a prescription from your doctor.

older mans lower half of body sitting down holding a ball in his hand with a person holding his arm in support

Skilled Nursing Facilities

If you are moved into a skilled nursing facility from the hospital or from an inpatient rehab facility, Medicare will only pay for your stay if you have satisfied the “3-day rule.” This means that you need to have been admitted as an inpatient into the hospital for three days, and not classified as an “observation care” patient. With Medicare, staying at one of these facilities is free to you for the first 20 days, and $176 per day for the next 80 days after that.

Long-Term Care Facilities

Medicare does not cover any long-term care facilities, even if your doctor deems it medically necessary. These services are not covered because care at these facilities includes things like bathing, feeding, and assisting with the bathroom, which Medicare does not consider medical care services.

Medicare Supplement Plans

There are obviously gaps in what Parts A and B cover when it comes to recovery from a stroke. A Medicare Supplement Plan can help to fill those gaps. Most plans will cover your Part A coinsurance and allow you to extend hospitalization days up to 365 days over your lifetime. A Medicare Supplement Plan will cover part or all of your Part A deductible, and approximately 8 out of 10 plans will cover the skilled nursing facilities coinsurance. Some also provide coverage for long-term care. There are 10 different types of plans to choose from, with different coverage and different price points. EZ’s highly trained, licensed agents can help you compare these plans,  and can provide quotes to you within minutes.calculator sitting on top of next to it.

We hope you never need to test the limits of Medicare’s coverage for stroke care. Speak to your doctor about your risk factors, such as high blood pressure, high cholesterol, diabetes, smoking, and drinking, and see if there are ways you might be able to lower your risk through healthy lifestyle changes. Suffering a stroke can be scary and life-changing, but if it does happen to you, Medicare will cover the majority of your costs for treatment and rehabilitation. And whatever it does not cover, you can always count on a Medicare Supplement Plan to help you pay your medical bills. To be better prepared and to save money, compare Medicare Supplement Plan quotes by entering your zip code in the bar above, or to speak directly to an agent call 888-753-7207.

Medicare’s “3-Day Rule” Lawsuit Goes To Trial

There was confusion and misinformation regarding the 3-day rule for skilled nursing facility coverage. In order to get the 100 days of skilled nursing coverage from Medicare, the mandate states a beneficiary must spend at least 3 days in the hospital as an inpatient. However, doctors and hospitals can admit elderly patients on an “observation stay,” which does not count as an “inpatient.” A class-action lawsuit ,filed back in 2011, challenged Medicare’s eligibility

Empty courtroom
Medicare’s 3 day ruling is finally going to be heard in the courtroom.

rules for skilled nursing coverage. Trial over the lawsuit is finally being heard in a federal courtroom.

Observation Stay

After an “observation stay,” senior patients are then discharged to a skilled nursing facility, complete with a bill. Because a substantial number of hospitals follow these routines, seniors are often forced to pay these bills out of pocket. Medicare will not cover the costs since it does not qualify as full admission.

In recent years, Medicare imposed strict limitations on hospital admittances. This explains why patients who are admitted are put under “observation.” Medicare pays one-third less for an observation patient than one who is in full admission. While Medicare benefits from these cost-saving tricks, it’s the patients that suffer.

Medicare Costs

Another way Medicare saves itself money is by shifting the cost of hip and/or knee replacements onto the beneficiaries. Medicare encourages doctors to perform these replacements as outpatient surgeries so that discharges happen within a few days.

Caucasian woman sitting in a hospital room hooked up to an IV.
Many doctors will put a patient under “observation stay” in order to bypass the rule, and have patients pay the bill out-of-pocket.

This has caused an uproar with patients because many of them simply cannot afford sky-high medical costs. So in turn, about 14 patients filed a class-action lawsuit. If they win, Medicare might have to reimburse almost 1.3 million beneficiaries.

President Trump’s Medicare chief, Seema Verma, listened to the complaints and voiced that something does have to change in order to help the beneficiaries. She stated, “We’ve talked a lot about the operational changes that we’re making, the policy changes that we’re making, but at the end of the day, this is about putting patients first.” If the 3-day rule does in fact change, the costly bill following a hospital visit will be alleviated, and many beneficiaries will be happy.