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Observational Status
En Español | If you are a Medicare beneficiary and are admitted at the hospital, you most likely will be admitted under an “Observation Status” while the physician or other healthcare practitioner responsible for your care determines that you will require further treatment at the hospital as an inpatient, or you are ready to be discharged.
There are two types of classification when admitted in a hospital, under an Outpatient Observational Status, meaning you are an outpatient and thus covered under Medicare part B, or as an Inpatient Admission and thus covered under Medicare part A.
It is very important to know if you are admitted under an observational status, so to be aware of the payments you will be responsible for while at the hospital and in the event you will need further assistance once discharged or transfer.
Hospitals should be providing the Medicare Outpatient Observation Notice (MOON) within 36 hours if the patient has been receiving observation services as an outpatient for 24 hours. The MOON cannot be appealed to Medicare.
Hospital Status Classification for Medicare Patients and their Coverage
INPATIENT ADMISSION:
Medicare Part A pays for “inpatient” hospital care. There is an initial deductible and if you stay for more than 60 days there is a copayment.
Medicare Part B pays for the care provided by physicians usually covering 80% of Medicare-approved costs.
Medigap or other supplemental insurance covers hospital deductibles, copayments, and Part B cost-sharing.
OBSERVATION STATUS:
Medicare Part A, as you are an outpatient, you will not be responsible for the inpatient deductible.
Medicare Part B and supplemental insurance, the hospital will charge Medicare Part B for any service provided, such as MRIs, EKGs, blood tests, intravenous medication, and lab tests. You will be responsible for any Part B co-payments and for the cost of any self-administered medication.
Your burden will be for the services provided by the nursing home care, in the event you would need it, and if you stayed less than three nights.
If you don’t have Medicare Part B, you will be responsible for the hospital’s entire bills, as well as any expenses in case you need nursing home care (usually covered by Medicare after a 3-day inpatient hospital stay, or 3-midnights).
Steps to Take if Placed Under an Observation Status
1. Find out your admission status, if you are admitted as an inpatient or on observation status.
2. Try to have your status changed. Seek the doctor’s help to be admitted as an inpatient.If the hospital insists in Observation Status, ask for a written notice stating this fact.
Tell the hospital the patient would like the status changed as the care is “medically necessary” for an “inpatient hospital level of care”.
Ask your regular doctor to help you by communicating with the hospital’s physician and intervening on your behalf. (As per the Centers of Medicare and Medigap, physicians should admit as an inpatient, patients that would require at least two midnights of care and the medical record supports it).
The Utilization Review Committee (URC) has the power to overturn physician’s admissions order.
3. If you need additional skilled care after discharge, these are the options:
Home Health Care: Ask your regular physician to order home health care. You will need to be homebound (leaving home requires considerable effort, and you require skilled nursing care or physical therapy or speech therapy).
Inpatient Rehabilitation Facility (IRF): If by the contrary you would need more care than the one provided at home, your physician can place a request for an IRF, they do not require the 3-day inpatient hospital stay.
Skilled Nursing Facility: If you need to go to a SNF, you need the 3-day hospital stay or you most likely will have to run with the costs.
RESOURCES
Phone: (860) 456.7790
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