Medicare Outpatient Vs Inpatient - Know The Difference

By: Meredith Miller
Published: Friday, October 26 2018
Last Updated: 20 days ago

It is important to understand the difference between Medicare inpatient and Medicare outpatient coverage. Medicare Part A covers inpatient hospital care, while Medicare Part B covers outpatient medical care. By understanding the difference in the two terms, you will be able to determine whether your Medicare coverage will be paying for your expenses.

Difference Between Medicare Outpatient And Inpatient

Inpatient means that your doctor has written orders for you to be admitted to the care of the hospital. Doctors must have admitting privileges at the hospital you are being admitted into. Once an order for admission is sent to the hospital, the hospital is instructed, by your admitting doctor, on how to treat your condition.

If you are sent to a hospital for diagnostic tests, have a same day surgery, or go to the emergency room, it is considered a Medicare outpatient event. Even if your doctor tells you to go to the emergency room, you are still considered outpatient. This is because your doctor didn't write an order admitting you to the hospital's care. If you stay the night for testing or in the ER, it is still considered a Medicare outpatient event.

How Medicare Pays For Inpatient Vs. Outpatient Care

Take a look at the differences between Medicare outpatient vs inpatient coverage. Part A is designed to pay for most Medicare inpatient expenses, but first your medical care provider must accept Medicare assignment. If they do, then your services will be covered. Part A covers your allowable expenses, including:

  • Semi-private rooms
  • Meals
  • General nursing
  • Other hospital services and supplies

Part A covers the care you receive in acute care, critical access hospitals, inpatient rehabilitation and long-term. It also covers Medicare inpatient care as part of a qualifying clinical research study, and Medicare inpatient mental health care in a psychiatric hospital or other hospital. You are responsible for paying your Part A deductible.

Your medical expenses as an Original Medicare beneficiary will be a $1,340 deductible for each Benefit period. This will increase for the 2019 year to $1,364. For days 1 through 60, you will not have to pay a coinsurance for each benefit period. For days 61 through 90, your coinsurance will be $335 per day of each benefit period. In 2019 this Coinsurance will increase to $341. For days 91 and beyond, your coinsurance will be $670 per each "lifetime reserve day", after day 90 for each benefit period (up to 60 days over your lifetime). The 2019 coinsurance amount will be $682. For any amounts beyond your lifetime reserve days, you will be responsible for all costs.

Medicare Part B covers medically necessary diagnostic and treatment services from a hospital that accepts Medicare Assignment. You're covered outpatient hospital services can include emergency or observation care. This includes overnight stays in the hospital where you are not admitted to inpatient. It also covers services in an outpatient clinic, like same-day surgery and laboratory tests. Mental health care in a partial hospitalization program can be covered by Medicare Part B. This is only covered if your doctor certifies that without this care, inpatient treatment would be necessary. Part B also covers X-rays and other radiology services, as well as medical supplies, like splints and casts. Part B covers preventive and screening services. As an Original Medicare recipient, you will pay 20 percent of the Medicare-approved amount. You are also responsible for your Part B deductible.

If you have a Medicare advantage plan, your coverage is equal to the benefits of the Original Medicare coverage.

What About For Prescription Drugs?

Medicare Part A pays for prescription drugs that are administered as part of your inpatient treatment. Medicare Part B does not cover prescription medication. However, it may cover certain drugs provided during outpatient care, like injections. These are drugs that are not usually self administered. Medicare Part D is designed to work with your Medicare plan to cover the expense of your prescriptions. If you are enrolled in a Medicare Advantage plan with prescription drug coverage, then your prescriptions are also covered.

Similarities Between The Two

It doesn't matter of you are considered inpatient or outpatient. For doctor services, you will pay your Part B deductible and 20 percent of the Medicare approved amount. Neither of the two covers the expense of private-duty nursing, a private room, television, phone, or personal care items.

Being Under Observation - The Middle Ground

If you are sent to the hospital for an observation period, it is usually so your doctor can decide whether or not to admit you. When you are under observation, it is usually considered as an outpatient event. Therefore, it should be covered under Medicare Part B.