Your Medicare Coverage
Is my test, item, or service covered?
Outpatient hospital services
How often is it covered?
Medicare Part B (Medical Insurance) covers medically necessary diagnostic and treatment services you get as an outpatient from a Medicare-participating hospital. Covered outpatient hospital services may include:
- Emergency or observation services, which may include an overnight stay in the hospital
- Services in an outpatient clinic, including same-day surgery
- Laboratory tests billed by the hospital
- Mental health care in a partial hospitalization program, if a doctor certifies that inpatient treatment would be required without it
- X-rays and other radiology services billed by the hospital
- Medical supplies, like splints and casts
- Preventive and screening services
- Certain drugs and biologicals that you wouldn’t usually give yourself. Generally, Part B doesn't cover prescription and over-the-counter drugs you get in an outpatient setting, sometimes called “self-administered drugs." Also, for safety reasons, many hospitals have policies that don’t allow patients to bring prescription or other drugs from home. If you have Medicare prescription drug coverage (Part D), these drugs may be covered under certain circumstances. You’ll likely need to pay out-of-pocket for these drugs and submit a claim to your drug plan for a refund. Call your drug plan for more information.
All people with Part B are covered.
Your costs in Original Medicare
- You generally pay 20% of the Medicare-approved amount for the doctor or other health care provider's services, and the Part B deductible applies.
- For all other services, you also generally pay a copayment for each service you get in an outpatient hospital setting. You may pay more for services you get in a hospital outpatient setting than you would pay for the same care in a doctor's office.
- For some screenings and preventive services, coinsurance, copayments, and the Part B deductible don't apply (so you pay nothing).
If you get hospital outpatient services in a critical access hospital (cah), your copayment may be higher and may exceed the Part A hospital stay deductible.
To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like:
- Other insurance you may have
- How much your doctor charges
- Whether your doctor accepts assignment
- The type of facility
- The location where you get your test, item, or service
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.
The copayment for a single outpatient hospital service can’t be more than the inpatient hospital deductible. However, your total copayment for all outpatient services may be more than the inpatient hospital deductible.