Outpatient Care

What is Outpatient Care?

Outpatient care is medical care that does not require an overnight stay in a hospital. Medicare Part B provides coverage for all medically necessary outpatient care services.[mfn referencenumber=1]Cigna.com, “What is Inpatient vs. Outpatient Care“, Accessed September 9, 2021[/mfn]

[keytakeaways]

• Outpatient care is healthcare services that do not require an overnight stay in a hospital.
• Outpatient care costs are covered under Medicare Part B.
• Outpatient care most often occurs in a doctor’s office or a health clinic.
• Outpatient care is more affordable than inpatient care.
• Outpatient costs can vary if using Medicare Advantage instead of Medicare Part A and B.

[/keytakeaways]

In most cases, outpatient care is received in a doctor’s office or a health clinic. It can also be received in a hospital emergency room. It is often for routine check-ups, medical equipment prescriptions like wheelchairs, and preventative care procedures at an outpatient clinic.[mfn referencenumber=2]Medicare.gov, “Part B costs“, Accessed September 9, 2021[/mfn]

Outpatient care is more affordable and does not interrupt a beneficiary’s daily life as much as hospitalization[mfn referencenumber=1]Cigna.com, “What is Inpatient vs. Outpatient Care“, Accessed September 9, 2021[/mfn]. An hour in the cardiology center getting regular blood work done is less disruptive and cheaper than spending time in urgent care recovering from a sudden heart attack.

How Much Does Outpatient Care Cost?

Outpatient care is covered by Medicare Part B, which has an annual deductible of $203 before coverage starts, meaning beneficiaries pay out-of-pocket for the first $203 for their outpatient services. This does not include their monthly premium which averages at $148.50 in 2021, depending on the beneficiary’s gross income. Once the deductible is met, Medicare provides an 80% coinsurance coverage for their outpatient costs.[mfn referencenumber=2]Medicare.gov, “Part B costs“, Accessed September 9, 2021[/mfn]

For Medicare Advantage plan members, the costs for outpatient care vary from plan to plan. Medicare Advantage plans must provide the same benefits as Medicare Part A and Part B, but they are allowed to set their own deductibles and copayments. In most cases, plan members will be required to use the plan’s network of providers. For non-emergency care, prior approval may be required.[mfn referencenumber=3]Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed September 9, 2021[/mfn]

What is the Difference Between Inpatient and Outpatient Care?

Outpatient care is health care that does not require hospitalization. Preventive care services like x-rays and radiation treatments for cancer fall under outpatient care. Benign medical procedures like getting a mole removed or receiving laser eye surgery also fall under outpatient care and require Medicare Part B for coverage.[mfn referencenumber=4]Medicare.gov, “Outpatient hospital services“, Accessed September 9, 2021[/mfn]

If a beneficiary requires an overnight stay at a hospital or a similar skilled health care facility, their treatments would be considered inpatient care. Inpatient care would require Medicare Part A to receive coverage[mfn referencenumber=5]Medicare.gov, “Inpatient hospital care“, Accessed September 9, 2021[/mfn].