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Inpatient vs Outpatient -What’s the Difference?

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If you’re receiving medical care, your primary concern may be to get the treatment you need. Your secondary concern may be to figure out how your care is being paid for. If you want to know how Medicare pays for your care, you may be interested in learning the difference of inpatient vs outpatient status.

Hospital inpatient vs outpatient – what is the difference?

Contrary to what you might think, the distinction of hospital inpatient vs outpatient isn’t determined by where you spend the night. In fact, you could spend a night in the hospital and still be considered an outpatient, according to the Centers for Medicare and Medicaid Services (CMS).

With Medicare, you’re only considered an inpatient when you’re formally admitted to a hospital per a doctor’s order. You’re an outpatient if a doctor hasn’t written an order to admit you to a hospital as an inpatient.

How does Medicare cover inpatient vs outpatient care?

Medicare Part A (hospital insurance) typically covers inpatient hospital care. Medicare Part B (medical insurance) generally covers outpatient care, including outpatient hospital services such as surgery, lab tests and x-rays. Medicare Part B also generally covers most of your doctor services when you’re a hospital outpatient.

If you’re in the hospital under observation, a doctor may wish to have time to decide whether or not to admit you as an inpatient or discharge you. If you’re in the hospital under observation, you’re generally still considered an outpatient.

What does inpatient vs outpatient care cost?

When you’re covered by Medicare Part B for outpatient services or doctor services when you’re an inpatient you generally pay:

  • Your Part B deductible
  • A coinsurance of 20% of the Medicare-approved amount for doctor services

If you’ve covered by Medicare Part A as an inpatient, you’ll generally pay:

  • A deductible for each benefit period
  • A coinsurance amount for inpatient days 61-90 for each benefit period.
  • Days 0-60 you generally pay a $0 coinsurance
  • Days 91 and beyond you pay for “lifetime reserve days” and when your lifetime reserve days are used up, you generally pay all costs unless you have additional insurance.

If you have a Medicare Advantage plan, your costs may be different. Medicare Advantage is another way to get your Medicare coverage from a private Medicare-approved insurance company. Medicare Advantage plans must cover everything that Original Medicare covers with the exception of hospice care, which is still covered by Medicare Part A.

A Medicare Supplement (Medigap) plan may also cover some inpatient vs outpatient costs beyond what Original Medicare (Part A and Part B) cover. For example, all Medicare Supplement plans generally cover the Medicare Part A coinsurance and hospital costs u to an additional 365 days after Medicare benefits are used up. All Medicare Supplement plans also generally cover the Medicare Part B coinsurance or copayment.

What else should I know about inpatient vs outpatient?

Medicare will generally only cover you for a Skilled Nursing Facility if you first have a “qualifying inpatient hospital stay.” Medicare defines a “qualifying inpatient hospital stay” as when you’ve been in the hospital as an inpatient admitted with a doctor’s order for at least 3 days in a row. Medicare counts the day before you’re discharged as your last inpatient day. So you may need to actually be in the hospital four days to qualify for skilled nursing facility care.

To find a Medicare Advantage or Medicare Supplement plan that can help cover inpatient and outpatient costs, enter your zip code on this page.

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