For those over the age of 65, Medicare is often an integral piece of the puzzle when it comes to health care. Medicare will pay for certain visits to the hospital. However, one important question will dictate what is paid for during that stay, and what may be paid for after you leave the hospital. That question is whether you are in the hospital as an “inpatient” or simply under “observation” status.
According to the website, Medicare.gov, an inpatient is defined as “Starting when you’re formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day.” In contrast, you are under observation status if you are getting emergency department services, observation services, outpatient surgery, lab tests, x-rays, or any other hospital services and the doctor hasn’t written an order to admit you to a hospital as an inpatient. You can be under observation status even if you spend the night in the hospital.
Generally, an inpatient admission is appropriate if it is expected by your doctor that you will need more than 2 nights in the hospital. However, the hospital must still formally admit you. It is not uncommon to spend more than 2 nights in the hospital while still being labeled as under observation status.
Along with the differences in hospital services that Medicare will cover, your status will also have an impact on whether or not Medicare will pay for a stay in a skilled nursing facility after you leave the hospital. Medicare will only cover your stay in a skilled nursing facility if you have a prior “qualifying inpatient hospital stay”. A qualifying inpatient hospital stay is when you were formally admitted to the hospital for at least 3 days in a row after your doctor writes an inpatient admission order. However, if you are in observation status for any of these days at the hospital, they will not be counted toward coverage of your stay in a skilled nursing facility.
Unfortunately, Medicare does not require hospitals to notify patients of their status. It is imperative that as a patient you understand your status and fight to be taken off observation status if you are in the hospital for a prolonged stay. The difference could mean thousands of dollars out of pocket to pay for a nursing home stay that Medicare may have otherwise paid for.
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