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Determining patient status

News from Area VI Agency on Aging

There is often confusion about how Medicare payments are affected by inpatient versus outpatient status in a hospital. The Senior Medicare Patrol sees many cases where beneficiaries are upset at how much they have to pay and think it must be incorrect. A hospital status, whether inpatient or outpatient, affects how much will be paid out of pocket for hospital services, and may affect whether Medicare will cover care received in a skilled nursing facility following a hospital stay if needed. Medical Part A will only pay covered expenses incurred when admitted as an inpatient. Any doctor services, including those provided in the hospital under observation status, will be covered by Part B, which covers medically necessary services at 80 percent. The patient of the patient’s Medigap plan will be responsible for 20 percent of medical costs. Even a stay overnight in a regular hospital bed may be classified as an outpatient under observation status. Inpatient status is only having been formally admitted to the hospital with a doctor’s order. Always ask, “Am I inpatient oroutpatient?” Medicare Part A will only pay for the first 100 days of skilled nursing care if there is a minimum three-day stay as a hospital inpatient and a doctor prescribes the nursing facility stay prior to returning home. Without the required three days as an inpatient, Medicare will not pay the skilled nursing facility at all. If Medicare won’t pay, a Medigap policy won’t pay either. If a stay in a skilled nursing facility covered by Medicare lasts for longer than 20 days, there will be a co-pay of $161 per day unless a Medigap plan covers it. So remember, it is very important to ask about inpatient or outpatient status each day of your stay, since it really does affect how much Medicare will pay. Medicare Advantage plans have their own rules about this, so check each individual plan. Contact SMP with billing concerns by calling 1-800-551- 3191 and asking for the Senior

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