Inpatient & Outpatient Services

Topics we will cover in this section:

• Inpatient Hospital Care
• Outpatient Hospital Services

Inpatient Hospital Care

Medicare Part A (Hospital Insurance) covers inpatient hospital care when all of these are true:

• You’re admitted to the hospital as an inpatient after an official doctor’s order, which says you need inpatient hospital care to treat your illness or injury.
• The hospital accepts Medicare.
• In certain cases, the Utilization Review Committee of the hospital approves your stay while you’re in the hospital.

Your costs in Original Medicare

• $1,408 deductible for each benefit period.
• Days 1–60: $0 coinsurance for each benefit period.
• Days 61–90: $352 coinsurance per day of each benefit period.
• Days 91 and beyond: $704 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime).
• Beyond lifetime reserve days : all costs.

What it is

Medicare-covered hospital services include:

• Semi-private rooms
• Meals
• General nursing
• Drugs as part of your inpatient treatment
• Other hospital services and supplies

Things to know

Inpatient mental health care in a psychiatric hospital is limited to 190 days in a lifetime.

Inpatient hospital care includes care you get in:

• Acute care hospitals
• Critical access hospitals
• Inpatient rehabilitation facilities
• Inpatient psychiatric facilities
• Long-term care hospitals
• Inpatient care as part of a qualifying clinical research study

Medicare Part B (Medical Insurance)

overs your doctors’ services you get while you’re in a hospital.

This doesn’t include:

• Private-duty nursing
• Private room (unless medically necessary )
• Television and phone in your room (if there’s a separate charge for these items)
• Personal care items, like razors or slipper socks

Outpatient Hospital Services

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 or outpatient clinic services, 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.

Your costs in Original Medicare

• You usually pay 20% of the Medicare-approved amount for the doctor or other health care provider’s services. For services that can also be provided in a doctor’s office, you may pay more for outpatient services you get in a hospital than you’ll pay for the same care in a doctor’s office. However, the hospital outpatient copayment for the service is capped at the inpatient deductible amount.
• In addition to the amount you pay the doctor, you’ll also usually pay the hospital a copayment for each service you get in a hospital outpatient setting, except for certain preventive services that don’t have a copayment. In most cases, the copayment can’t be more than the Part A hospital stay deductible for each service.
• The Part B deductible applies, except for certain preventive services . If you get hospital outpatient services in a critical access hospital, your copayment may be higher and may exceed the Part A hospital stay deductible.