Observation (Outpatient) and Inpatient Hospital Care
By Barb Zebley-Oldani, LBSW, Care Coordination Program Director
With the start of the New Year, it seems like a good time to review your Medicare benefits related to the care received at a hospital. Did you know that even if you stay overnight at the hospital you may not be considered “admitted,” but in observation or receiving outpatient
hospital services? The decision for admission to a hospital is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care. You become an inpatient when a hospital formally admits you as an inpatient, after a doctor orders it. Knowing your hospital status of admission versus observation is important. Your hospital status affects how much you pay for hospital services and whether you are eligible for Medicare covered skilled nursing facility care after your hospitalization.
If you are in observation care (not admitted) at the hospital, your services will be billed to Medicare Part B. Even if you stay overnight in a hospital bed, you might be in observation or outpatient status. Medicare Part B covers outpatient hospital services. You pay a copayment for each individual outpatient hospital service you receive, paying 20% of the Medicare-approved amount after you pay the Part B annual deductible of $147 (for 2015). If you remain in observation status throughout your entire stay (not admitted), you are not eligible for Medicare covered skilled nursing facility care after your hospitalization.
If you are admitted to the hospital, your services will be billed to Medicare Part A. Medicare Part A covers a semi-private room, meals, general nursing, and drugs as part of your inpatient treatment and other hospital services and supplies. Medicare Part B covers the doctor services you get while you’re in a hospital. You pay a $1,260 deductible and no coinsurance for days
1-60 of each benefit period. The Medicare and You 2015 handbook explains other costs if you continue to remain in the hospital after 60 days. A hospital benefit period begins the day you’re admitted as an inpatient in a hospital and ends when you haven’t received any inpatient hospital care (or skilled nursing facility care) for 60 days in a row. If you go back to the
hospital for another admission (for the same or different medical condition) during the same hospital benefit period, you do not pay the deductible again. If you go into the hospital after a hospital benefit period ends, you must pay the hospital deductible ($1,260) in this new benefit period.
Medicare will only cover skilled nursing care if you first have a qualifying inpatient (not
observation status) hospital stay. A qualifying inpatient hospital stay means that you have been admitted to the hospital for 3 consecutive days (counting the day you’re admitted, but not counting the day of your discharge). You pay nothing for covered skilled nursing facility services for the first 20 days, then a copayment for days 21-100. Medicare will not pay
beyond 100 days.
All individuals with Medicare have certain guaranteed rights. You have the right to have your questions about Medicare answered and get a decision about health care payment or services. You have the right to get a review (appeal) and file a complaint (sometimes called a “grievance”) of certain decisions about health care payment and coverage of services.
Your medical provider can answer most of your Medicare questions. If you need further
assistance, call Senior Services at 989-633-3700. Consultations are available throughout the year for those who would like assistance with Medicare questions or options.