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CENTERS FOR MEDICARE & MEDICAID SERVICES

Are You a Hospital Inpatient or Outpatient?

If You Have Medicare – Ask!

Did you know that even if you stay in the hospital overnight, you might still be

considered an “outpatient”? Your hospital status (whether the hospital considers

you an “inpatient” or “outpatient”) affects how much you pay for hospital

services (like X-rays, drugs, and lab tests). Your hospital status may also affect

whether Medicare will cover care you get in a skilled nursing facility (SNF). 

An inpatient admission begins the day you’re formally admitted to the hospital

with a doctor’s order. The day before you’re discharged is your last inpatient day.

You’re an outpatient if you’re getting emergency department services, observation

services, lab tests, or X-rays, and the doctor hasn’t written an order to admit you

as an inpatient even if you spend the night at the hospital. 

If you’re in the hospital more than a few hours,

always ask your doctor or the hospital staff if you’re

an inpatient or an outpatient.

Read on to understand the differences in Original Medicare coverage for hospital

inpatients and outpatients and how these rules apply to some common situations.

If you have a Medicare Advantage Plan (like an HMO or PPO), costs and

coverage may be different. Check with your plan.

What do I pay as an inpatient?

Medicare Part A (Hospital Insurance) covers inpatient hospital services. Generally,

this means you pay a one-time deductible for all of your hospital services for the

first 60 days you’re in the hospital. 

Medicare Part B (Medical Insurance) covers most of your doctor services when

you’re an inpatient. You pay 20% of the Medicare-approved amount for doctor

services after paying the Part B deductible. 
Publication No. CMS-11065

December 2004

What do I pay as an outpatient?

Medicare Part B covers outpatient hospital and doctor services. Generally, this

means you pay a copayment for each individual outpatient hospital service.

This amount may vary by service.

Note: The copayment amount for a single outpatient hospital service can’t be

more than the inpatient hospital deductible. In some cases, your total copayment

for all services may be more than the inpatient hospital deductible. 

Part B also covers most of your doctor services when you’re a hospital outpatient.

You pay 20% of the Medicare-approved amount after the Part B deductible.

Generally, the prescription and over-the-counter drugs you get in an outpatient

setting like an emergency department (sometimes called “self-administered

drugs”) aren’t covered by Part B. If you have Medicare Part D prescription drug

coverage, these drugs may be covered under certain circumstances. You will likely

need to pay out-of-pocket for these drugs and submit a claim to your drug plan

for a refund. Call your plan for more information. 

For more detailed information on how Medicare covers hospital services,

including premiums, deductibles, and copayments, visit

www.medicare.gov/Publications/Pubs/pdf/10050.pdf to view the “Medicare &

You” handbook. You can also call 1-800-MEDICARE (1-800-633-4227). 

TTY users should call 1-877-486-2048. 

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Below are some common situations and a description of how Medicare will pay.

Remember, you pay deductibles, coinsurance, and copayments.

Situation Inpatient or

Outpatient Part A Pays Part B Pays

You’re in the emergency

department, and then you’re

formally admitted to the 

hospital with a doctor’s order.

Inpatient Your hospital stay 

usually including 

emergency department

services

Your doctor services

You visit the emergency

department for a 

broken arm, get X-rays and

a cast, and go home.

Outpatient Nothing Doctor services and 

hospital outpatient 

services (for example,

emergency department

visit, X-rays, casting)

You come to the emergency

department with chest pain,

and the hospital keeps you

for 2 nights for observation 

services.

Outpatient Nothing Doctor services and 

hospital outpatient 

services (for example,

emergency department

visit, observation 

services, lab tests, EKGs)

You come to the hospital for

outpatient surgery, but they

keep you overnight for high

blood pressure. Your doctor

doesn’t write an order to

admit you as an inpatient.

You go home the next day.

Outpatient Nothing Doctor services and

hospital outpatient

services

Your doctor writes an order

for you to be admitted as an

inpatient and the hospital

later tells you they’re 

changing your status to 

outpatient. Your doctor must

agree, and the hospital must

tell you in writing - while

you’re still in the hospital -

that your status changed.

Outpatient Nothing Doctor services and

hospital outpatient

services
REMEMBER: Even if you stay overnight in a regular hospital bed, you might be

an outpatient. Ask the doctor or hospital.

How would my hospital status affect the way that

Medicare covers care I get in a skilled nursing facility

(SNF)?

Medicare will only cover care you get in a SNF if you first have a “qualifying hospital

stay.” A qualifying hospital stay means you’ve been a hospital inpatient for at least 3

days in a row (counting the day you were admitted as an inpatient, but not counting

the day of your discharge). If you don’t have a 3-day inpatient hospital stay, ask if you

can get care after your discharge in other settings (like home health care) or if any

other programs (like Medicaid or Veterans’ benefits) can cover your SNF care. Always

ask your doctor or hospital staff if Medicare will cover your SNF stay.

How would a hospital’s observation services affect

my SNF coverage?

Your doctor may order “observation services” to help decide whether you need to be

admitted to the hospital as an inpatient or can be discharged.

During the time you’re getting observation services in the hospital, you’re considered

an outpatient. This means you can’t count this time towards the 3-day inpatient

hospital stay needed for Medicare to cover your SNF stay. 

For more information about how Medicare covers care in a SNF, visit

www.medicare.gov/Publications/Pubs/pdf/10153.pdf to view the booklet “Medicare

Coverage of Skilled Nursing Facility Care.”

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How would a hospital’s observation services affect my SNF

coverage? (continued)

Below are some common hospital situations that may affect your SNF coverage.

Situation Is your SNF stay covered?

You came to the emergency department

and were formally admitted to the 

hospital with a doctor’s order as an 

inpatient for 3 days, and you were 

discharged on the fourth day. 

Yes, you met the 3-day inpatient stay

requirement for a covered SNF stay. 

You came to the emergency department

and spent 1 day getting observation

services. Then, you were an inpatient

for 2 more days. 

No. Even though you spent 3 days in the

hospital, you were considered an outpatient

while getting emergency department and

observation services. These days don’t count

toward the 3-day inpatient stay requirement.

Remember: An inpatient admission begins the day you’re formally admitted to the

hospital with a doctor’s order. That date is your first inpatient day. The day you are

discharged doesn’t count as an inpatient day.

What are my rights?

No matter what type of Medicare coverage you have, you have certain guaranteed rights.

As a person with Medicare, you have the right to all of the following:

• Have your questions about Medicare answered

• Learn about all of your treatment choices and participate in treatment decisions

• Get a decision about health care payment or services, or prescription drug coverage

• Get a review of (appeal) certain decisions about health care payment, coverage of

services, or prescription drug coverage

• File complaints (sometimes called grievances), including complaints about the quality

of your care

For more information about your rights, the different levels of appeals, and Medicare

notices, visit www.medicare.gov/Publications/Pubs/pdf/10112.pdf to view the booklet

“Your Medicare Rights and Protections.” You can also call 1-800-MEDICARE 

(1-800-633-4227). TTY users should call 1-877-486-2048.
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CMS Product No. 11435

December 2009

Where can I get more help?

• For more information on Part A and Part B coverage, read your “Medicare & You”

handbook, or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 

1-877-486-2048.

• For more information about coverage of self-administered drugs, view the publication

“How Medicare Covers Self-administered Drugs Given in Outpatient Settings” by

visiting www.medicare.gov/Publications/Pubs/pdf/11333.pdf. 

• To ask questions or report complaints about the quality of care for a Medicarecovered service, call your Quality Improvement Organization (QIO). Call 

1-800-MEDICARE to get the telephone number. Or, visit www.medicare.gov, and

select “Find Helpful Numbers and Websites.”

• To ask questions or report complaints about the quality of care or the quality of life

in a nursing home, call your State Survey Agency. Call 1-800-MEDICARE to get the

telephone number. Or, visit www.medicare.gov, and select “Find Helpful Numbers

and Websites.”