Inpatient Admission vs. Observation

Hospital Status

Every patient is assigned a status when they’re admitted to the hospital. Inpatient status and observation status are the two most common. When you’re admitted, it’s not always easy to know which status you’ve been given. For instance, you could be placed in a room with inpatients, when you’re actually an outpatient under observation.

Inpatient Admission vs. Outpatient Hospital Observation

If you’re admitted as an inpatient, it means you’ll stay for multiple nights in the hospital and get special care for a serious illness or injury. But observation services are hospital outpatient services given to see whether you need to be admitted as an inpatient or if you can be discharged.

For outpatient hospital observation services to be covered by Braven Health, they must meet the Medicare criteria and be considered reasonable and necessary.

Observation services are covered only when they’ve been ordered. That order has to come from a doctor or hospital employee authorized by state law and hospital staff bylaws to admit patients to the hospital or order outpatient tests.

Note: If someone from the hospital hasn’t written an order to admit you as an inpatient, you’re an outpatient. This means you pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you’re not sure if you’re an outpatient, you should ask the hospital staff.

What You’ll Pay as a Braven Health Member

Your hospital and Braven Health will be in communication about your status, to be sure they’re on the same page about your coverage. Here’s a breakdown of the two hospital statuses and what you’ll likely have to pay for.

For Outpatient Hospital Observation

As a Braven Health member, you’ll pay one copayment for observation services. But, if a provider bills for services other than observation, you may be responsible for added cost-sharing.

For Inpatient Care

Inpatient hospital care starts the day you’re formally admitted to the hospital as an inpatient with a doctor’s order. The day before you’re discharged is your last inpatient day.

There’s no limit to the number of days covered by Braven Health for each hospital stay. Covered services include but aren’t limited to:

• A semi-private room (or a private room, if medically necessary)
• Meals, including special diets
• Regular nursing services
• Costs of special care units (like intensive care or coronary care)
• Medicines
• Lab tests
• X-rays and other radiology services
• Necessary surgical and medical supplies
• Use of appliances, like wheelchairs
• Operating and recovery room costs
• Physical, occupational and speech language therapy
• Inpatient substance abuse services

You’ll have to pay a copayment for the first five days in the hospital. Then you’ll pay $0 for days six and beyond.

When you’re admitted to a hospital, you have the right to get all of your covered hospital services that are necessary to diagnose and treat you.

During your covered hospital stay, your doctor and the hospital staff will work with you to get you ready for the day you leave. They’ll help arrange for care you might need after you get out of the hospital.

• The day you leave the hospital is called your discharge date.
• Your doctor or the hospital staff will tell you when your discharge date will be.
• If you think you’re being asked to leave too soon, you can ask for a longer hospital stay and your request will be considered.

Check Your Status

Keep in mind the main differences between inpatient and outpatient status:

• You’re an inpatient starting when:
  • You’re formally admitted to the hospital with a doctor's order. The day before you're discharged is your last inpatient day.

• You’re an outpatient if the doctor hasn't written an order to admit you to a hospital as an inpatient and you’re getting:
  • Emergency department services
  • Observation services
  • Outpatient surgery
  • Lab tests
  • X-rays
  • Any other hospital services

In these cases, you're an outpatient even if you spend the night in the hospital.

Remember that even if you stay overnight under observation in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital. You should be given a Medicare Outpatient Observation Notice (MOON) that tells you you’re an outpatient, if you're getting outpatient observation services for more than 24 hours.

The MOON will tell you why you’re an outpatient getting observation services, instead of an inpatient. It also says how this may affect what you pay while in the hospital and for care you get after leaving the hospital.

Call Braven If You Need Help

If you have any questions about your inpatient or outpatient status, contact Braven Health’s Member Services: 1-833-272-8360 (TTY 711), Monday to Sunday, 8 a.m. to 8 p.m. You can also review your plan’s Evidence of Coverage for more details. Visit BravenHealth.com to download your plan documents.