Your questions on Medicare and Medicaid answered by the local State Health Insurance Assistance Program (SHIP) an objective, not-for-profit counseling, assistance and advocacy service sponsored by DPHHS of Montana and Centers for Medicare & Medicaid Services.
Q: I recently was in the hospital but it wasn’t covered by my hospitalization. They said I was under “outpatient observation”. What does this mean?
A: Outpatient observation is used for patients who have medical conditions that require short term treatment before a decision is made whether they will be admitted for an inpatient stay or discharged. For traditional Medicare, observation service should not last more than 48 hours. While under outpatient observation the cost of your care will be covered by Medicare Part B and have the same deductibles and copays as other Medicare Part B services.
Q: My Medicare didn’t pay for my medicines while I was under observation. Why not?
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A: The routine medications you would take at home, if administered at the hospital under outpatient observation will not be covered by Medicare Part B but instead be covered by your Medicare Part D Prescription Drug plan. You will have to request reimbursement from you plan for the cost of the medications dispensed by the hospital. The plan is only liable for the costs their plan would normally cover at your pharmacy.
Q: When I went into the nursing home after my time in the hospital under outpatient observation my nursing home cost weren’t covered by Medicare. Why not?
A: Outpatient observation days do not count toward the 3 inpatient hospital days needed to qualify for the traditional Medicare skilled nursing facility benefit.
As a good medical consumer, you or your family will have to ask the hospital staff to verify if you are actually an inpatient client or an outpatient client so you will be aware of the cost for your care and you additional Medicare options. For more information on this issue read the Medicare publication at https://www.medicare.gov/sites/default/files/2018-09/11435-Are-You-an-Inpatient-or-Outpatient.pdf or call Medicare at 1-800-MEDICARE and asked to be mail CMS publication # 11435.
Do you have a question about Medicare or Medicaid that you would like answered? Please send your question to SHIP Program c/o Adult Resource Alliance, 1505 Avenue D, Billings, MT 59102 or firstname.lastname@example.org