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What You Need to Know About Medicare Coverage for Inpatient Stays

courtesy of DailyCaring.com

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Surprise! It's Not Covered

Imagine that your mom fell, broke her hip, and has been in the hospital for almost a week. When the hospital is ready to discharge her, you suddenly find out that Medicare won't cover any of the cost for her stay in the skilled nursing facility she's moving to. And, there will be hospital bills coming your way.

Why?!? This is because she was never actually admitted to the hospital by the doctor, which means she wasn't inpatient. She was considered an outpatient and Medicare doesn't cover as much for outpatients.

Hospital Status: Inpatient vs Outpatient

A hospital classifies a patient's status as either inpatient or outpatient. Inpatients are those who have been admitted to the hospital under doctor's orders.

Don't assume you know their status based on what procedures are being done or how long your senior has been in the hospital. No matter what's happening, they could still be classified as an outpatient under observation status.

Why Is Hospital Status Important?

Hospital status affects Medicare coverage for hospital stays and post-hospital care. The difference could mean thousands of dollars out of your older adult's pocket.

When someone is admitted as an inpatient is very important. Medicare only covers the inpatient portion of a hospital stay.

So, any time spent in the hospital or emergency room before being admitted is considered outpatient time, will be covered under outpatient coverage rules, and doesn't count toward the three-day minimum for covered skilled nursing care. It's also important to know that the discharge day doesn't count as an inpatient day.

What Seniors Should Expect to Pay

What seniors pay as inpatients:

  • For the first 60 days of hospital services, pay the Part A deductible.
  • For doctor's services, pay the Part B deductible plus 20% of the Medicare-approved amount.
  • or nursing home/rehab care, if the inpatient stay has been at least three days, only pay after the first 20 days (fully covered) in an approved skilled nursing facility.

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What seniors pay as outpatients:

  • For hospital services, pay a copayment for each individual outpatient hospital service. This amount may vary by service.
  • For doctor's services, pay the Part B deductible plus 20% of the Medicare-approved amount.
  • For prescription and over-the-counter medications in the hospital or emergency room, pay out-of-pocket (and try to submit a claim to the drug plan later) or try to use Part D prescription drug coverage.
  • For nursing home/rehab care, pay out-of-pocket.

Bottom Line

It's critical to know your older adult's hospital status, so you won't be shocked by huge bills. Medicare coverage is different depending on their hospital status, inpatient versus outpatient under observation.

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