Original Medicare (Parts A & B): Outpatient Hospital Services

Medicare covers many diagnostic and treatment services received as an outpatient from a Medicare-certified hospital. Generally, the member pays 20% of the Medicare-approved amount for provider services. They may pay more for services they receive in a hospital outpatient setting than they'll pay for the same care in a provider's office.

In addition to the amount they pay the provider, they'll also usually pay the hospital a copay for each service they receive in a hospital outpatient setting (except for certain preventive services that don't have a copay). In most cases, the copay cannot be more than the Part A hospital stay deductible for each service. The Part B deductible applies, except for certain preventive services.

If the member gets hospital outpatient services in a critical access hospital, the copay may be higher and may exceed the Part A hospital stay deductible.

Medically necessary services in the outpatient department of a hospital for diagnosis or treatment of an illness or injury are covered.

Covered services include, but are not limited to

• Services in an emergency department or outpatient clinic, such as observation services or ambulatory/outpatient surgery center

• Laboratory and diagnostic tests billed by the hospital

• Mental health care, including care in a partial-hospitalization program (PHP), if a provider certifies that inpatient treatment would be required without it

• X-rays and other radiology services billed by the hospital

• Medical supplies such as splints and casts

• Certain drugs and biologicals that cannot be self-administered

To get cost estimates for outpatient hospital services, click here.

Blood

Blood transfusion is necessary for a number of planned and unplanned circumstances and can mean the difference between life and death. There are circumstances when blood transfusion is at no cost (save a portion of processing and handling fees), though it is likely the member will be charged for the first 3 units.

If the hospital gets blood from a blood bank at no charge, those savings are passed on to the member and there are no replacement fees. However, the member will pay a copayment for the blood processing and handling services for each unit they receive.

Likewise, if the member or someone else donates the blood (such as a family member who is a match), there is no cost.

However, if the hospital must purchase blood for the member, they will pay the hospital costs for the first 3 units in a calendar year.

Unless the provider has written an order for inpatient admission to the hospital, the episode is considered outpatient and cost-sharing amounts for outpatient hospital services apply. Even if there is an overnight hospital stay (rare), it may still be considered outpatient. If outpatient versus inpatient status isn’t clear, ask the hospital staff.