Medicare Coverage of Hospital Outpatient Care
What It Is
Care provided by a hospital outpatient department (when the patient isn't admitted to the hospital as an inpatient)
Medicare Part B covers medically necessary services provided to an outpatient by a Medicare-participating hospital for diagnosis or treatment of an illness or injury.
Covered services include:
- Emergency room care
- Outpatient clinic care, including surgery that doesn't require hospital admission
- Laboratory tests provided or billed by the hospital
- X-rays, CT scans, MRIs, and other radiology services provided or billed by the hospital
- Physical therapy
- Medical supplies provided by the hospital
- Drugs administered by the hospital because the patient isn't able to administer them
Note: Special limitations and payment rules apply to physical therapy provided at a hospital outpatient department.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for hospital outpatient care, contact the plan directly.
What Medicare Pays
Medicare Part B pays 80 percent of the Medicare-approved amount for doctor services provided in a hospital outpatient department. Medicare Part B pays the full Medicare-approved amount for all nondoctor hospital outpatient services, except for a patient co-payment amount that varies with each type of service.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.
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