Medicare Explained: Inpatient vs.Outpatient Care

Inpatient 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

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

What do I pay as an inpatient?

  • Medicare Part A covers inpatient hospital services. Generally, this means you pay a one-time deductible for all of your hospital services for the first 60 days you’re in a hospital.
  • Medicare Part B (Medical Insurance) covers most of your doctor services when you’re an inpatient. You pay 20 percent of the Medicare-approved amount for doctor services after paying the Part B deductible.

Specific costs include:

  • $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.

Outpatient Care

Medicare Part B (Medical Insurance) covers many 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 prescriptions 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.

What do I pay as an outpatient?

  • Part B covers outpatient hospital services. Generally, this means you pay a copayment for each outpatient hospital service. This amount may vary by service.
    Note: 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.
  • Part B also covers most of your doctor services when you’re a hospital outpatient. You pay 20 percent of the Medicare-approved amount after you pay the
    Part B deductible.
  • Generally, prescription and over-the-counter drugs you get in an outpatient setting (like an emergency department), sometimes called “self-administered drugs,” aren’t covered by Part B. Also, for safety reasons, many hospitals have policies that don’t allow patients to bring prescriptions 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.

Other services

Hospice care 

Hospice care is for people with a life expectancy of 6 months or less. This kind of care is done by a team that includes you and your family, as well as doctors, nurses, social workers, pharmacists, and other team members. You can get hospice care for two 90-day benefit periods, followed by an unlimited number of 60-day benefit periods (if you are recertified to have a low life-expectancy). To find hospice care, search Medicare’s Hospice Compare site.

Hospice care includes:

  • Doctor services
  • Nursing care
  • Pain relief medications
  • Social services
  • Durable medical equipment
  • Medical supplies
  • Hospice aide services
  • Homemaker services
  • Physical and occupational therapy
  • Dietary counseling
  • Short-term inpatient care (if necessary for managing pain or symptoms)
  • Short-term respite care

Home health services

Home health services are only covered if a doctor certifies that you are homebound, you are under the care of a doctor, and you are in need of the services listed below. Note that Part A will not cover around-the-clock home care except in short-term special circumstances that your condition requires. If in doubt about whether Medicare covers something, talk to your doctor, or search Medicare’s site

Home health services include:

  • Intermittent skilled nursing care
  • Physical therapy
  • Speech-language pathology services
  • Continued occupational services, and more.

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