Are You a Hospital Inpatient or Outpatient?

If You Have Medicare – Ask!

Revised August 2018

Did you know that even if you stay in a 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) and may also affect whether 

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

your hospital stay. 

• You’re an inpatient starting when you’re formally admitted to a 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, outpatient surgery, lab tests, X-rays, or any other 

hospital services, and the doctor hasn’t written an order to admit you to a 

hospital as an inpatient. In these cases, you’re an outpatient even if you spend 

the night at the hospital. 

Note: Observation services are hospital outpatient services given to help the 

doctor decide if you need to be admitted as an inpatient or can be discharged. 

Observation services may be given in the emergency department or another 

area of the hospital. 

The decision for inpatient hospital admission is a complex medical decision 

based on your doctor’s judgment and your need for medically necessary 

hospital care. An inpatient admission is generally appropriate for payment 

under Medicare Part A when you’re expected to need 2 or more midnights 

of medically necessary hospital care, but your doctor must order this 

admission and the hospital must formally admit you for you to become an 

inpatient.

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), your costs and coverage may be different. Check with your plan.
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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 a 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. 

What do I pay as an outpatient?

• Part B covers outpatient hospital services. Generally, this means you pay a 

copayment for each outpatient hospital service. This amount may vary by service. 

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

than the inpatient hospital deductible. However, your total copayment for all 

outpatient 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 you pay the 

Part B deductible. 

• Generally, 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. Also, for safety reasons, many hospitals have 

policies that don’t allow patients to bring prescription or other drugs from home. 

If you have Medicare prescription drug coverage (Part D), these drugs may be 

covered under certain circumstances. You’ll likely need to pay out-of-pocket for 

these drugs and submit a claim to your drug plan for a refund. Call your drug 

plan for more information. 

For more detailed information on how Medicare covers hospital services, 

including premiums, deductibles, and copayments, visit Medicare.gov. You can 

also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 

1-877-486-2048.
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Here are some common hospital 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 (ED) (also known as 

the emergency room or “ER”) and 

then you’re formally admitted to 

the hospital with a doctor’s order.

Outpatient until you’re 

formally admitted as 

an inpatient based on 

your doctor’s order. 

Inpatient after your 

admission.

Your inpatient 

hospital stay 

and all related 

outpatient services 

provided during 

the 3 days before 

your admission 

date. 

Your doctor services

You come to the ED with chest 

pain and the hospital keeps you 

for 2 nights. One night is spent in 

observation and the doctor writes 

an order for inpatient admission on 

the second day.

Outpatient until you’re 

formally admitted as 

an inpatient based on 

your doctor’s order. 

Inpatient after your 

admission.

Your inpatient 

hospital stay 

and all related 

outpatient services 

provided during 

the 3 days before 

your admission 

date.

Your doctor services 

You go to a 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 (for example, 

surgery, lab tests, or 

intravenous medicines)

Your doctor writes an order for 

you to be admitted as an inpatient, 

and the hospital later tells you 

it’s changing your hospital status 

to outpatient. Your doctor must 

agree, and the hospital must tell 

you in writing – while you’re still 

a hospital patient before you’re 

discharged – that your hospital 

status changed from inpatient to 

outpatient.

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.
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How would my hospital status affect the way Medicare 

covers my care in a skilled nursing facility (SNF)? 

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

inpatient hospital stay.”

• A qualifying inpatient hospital stay means you’ve been a hospital inpatient (you 

were formally admitted to the hospital after your doctor wrote an inpatient 

admission order) 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 and you need care after your 

discharge from a hospital, ask if you can get care 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 hospital observation services affect my SNF 

coverage? 

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

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

you’re getting observation services in a hospital, you’re considered an outpatient. 

This means Medicare won’t count this time towards the 3-day inpatient hospital 

stay needed for Medicare to cover your SNF stay.

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

coverage may be different. Check with your plan.

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

Medicare.gov 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) 

Here are some common hospital situations that may affect your 

SNF coverage:

Remember: Any days you spend in a hospital as an outpatient (before you’re 

formally admitted as an inpatient based on the doctor’s order) aren’t counted as 

inpatient days. An inpatient stay begins on the day you’re formally admitted to a 

hospital as an inpatient with a doctor’s order. That’s your first inpatient day. The day 

of discharge 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 these:

• 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 Medicare.gov to view the booklet “Medicare Rights & 

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

(TTY: 1-877-486-2048).

Situation Is my SNF stay covered?

You came to the ED and were formally 

admitted to the hospital with a doctor’s 

order and spent 3 days in the hospital as 

an inpatient after admission. You were 

discharged on the 4th day.

Yes, if all other coverage requirements are 

met. You met the 3-day inpatient hospital 

stay requirement for a covered SNF stay.

You came to the ED and spent one day 

getting observation services. Then, you 

were formally admitted to the hospital as 

an inpatient for 2 more days. 

No. Even though you spent 3 days 

in the hospital, you were considered 

an outpatient while getting ED and 

observation services. These days don’t 

count toward the 3-day inpatient hospital 

stay requirement. 
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Where can I get more help? 

• If you need help understanding your hospital status, talk to your doctor or 

someone from the hospital’s utilization or discharge planning department. 

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

You” handbook, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). 

(TTY: 1-877-486-2048).

• For more information about coverage of self-administered drugs, visit 

Medicare.gov to view the publication “How Medicare Covers Self-administered 

Drugs Given in Hospital Outpatient Settings”, or call 1-800-MEDICARE.

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

Medicare-covered service, call your Quality Improvement Organization (QIO). 

Visit Medicare.gov, or call 1-800-MEDICARE to get the phone number. 

• To ask questions or report complaints about your care in a nursing home, 

call your State Survey Agency. Visit Medicare.gov with a link to 

Medicare.gov/NursingHomeCompare/Resources/State-Websites.html, or call 

1-800-MEDICARE to get the phone number. 
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Notes
CMS Product No. 11435

You have the right to get Medicare information in an accessible format, like large 

print, Braille, or audio. You also have the right to file a complaint if you feel you’ve 

been discriminated against. Visit Medicare.gov/about-us/nondiscrimination/

accessibility-nondiscrimination.html, or call 1-800-MEDICARE 

(1-800-633-4227) for more information. TTY users can call 1-877-486-2048.

Paid for by the Department of Health & Human Services.