A. Understanding whether or not you are considered a hospital
inpatient or outpatient is very important for Medicare beneficiaries. It determines what and how much Medicare will pay for during and after your hospital stay. Even if you stay in the hospital overnight you may not be considered to be inpatient. Below please find the alert from the Medicare Advocacy Project on this subject. You can also read a Medicare document on this same issue here: www.medicare.gov.
Medicare Beneficiary Alert:
Are You a Hospital Inpatient?
If you are a Medicare beneficiary, Medicare can pay for up to 100 days of care in a Skilled Nursing Facility (SNF) such as a nursing home. Unless you are in a Medicare Advantage plan which allows otherwise, to qualify for Medicare coverage, among other criteria, you must have a qualifying hospital stay of 3 consecutive days or more and need doctor-ordered skilled care or therapy on a daily basis. However, a three-day hospital stay is not a guaranty that Medicare will pay for SNF care. The stay must be considered an inpatient hospitalization.
Recently it has come to the attention of the Medicare Advocacy Project that some Medicare beneficiaries have been admitted to a hospital for days, if not weeks, at a time, while during that time their hospital considered them as under “observation status.” If a person is in a hospital under observation status, instead of as an inpatient, those days in the hospital will not count as part of the 3 days hospital days needed before Medicare will cover care at a Skilled Nursing Facility. Not only does your inpatient or observation status impact whether Medicare will pay for your SNF stay, but also it can change the amount you will pay for the services and medications you receive while in the hospital.
Medicare beneficiaries should take the following steps to protect their right to appropriate Medicare coverage:
- Make sure to ask your doctor or other hospital staff whether you are considered an inpatient or under observation status. Be aware that some hospitals change a person’s status during the course of his or her stay, so make sure to ask this question multiple times when you are in the hospital. If possible, ask for a decision in writing.
- Review any notices you receive carefully. Some hospitals and SNFs will issue “Advanced Beneficiary Notices” or “Notices of Exclusion from Medicare Benefits” which may explain when Medicare coverage is and is not available.
- If you think you should be an inpatient, or that Medicare should cover your SNF stay, explore your appeal rights. If you disagree with a Medicare claims or services decision, you can file an appeal.
The Medicare Advocacy Project (MAP) is devoted to assisting people who may have been wrongfully denied Medicare. If you have questions about your Medicare claims or need legal advice, contact your local MAP office via Greater Boston Legal Services at 1-800-323-3205. For Worcester County residents, contact Community Legal Aid at 1-855-CLA-LEGAL.
For those individuals that live outside of Massachusetts you can find local resources by using Elder Care Locator at eldercare.gov or call 1-800-677-1116.
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