What is Outpatient Care?
Outpatient care is medical care that does not require an overnight stay in a hospital. Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. provides coverage for all medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. outpatient care services.1Cigna.com, “What is Inpatient vs. Outpatient Care“, Accessed September 9, 2021
Key Takeaways
- 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 careInpatient care refers to care provided in a hospital or other inpatient facility. Inpatients are admitted and stay at least one night depending on their condition..
- Outpatient costs can vary if using Medicare Advantage instead of Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and B.
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.2Medicare.gov, “Part B costs“, Accessed September 9, 2021
Outpatient care is more affordable and does not interrupt a beneficiary’s daily life as much as hospitalization1Cigna.com, “What is Inpatient vs. Outpatient Care“, Accessed September 9, 2021. 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 premiumA premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. which averages at $148.50 in 2021, depending on the beneficiary’s gross income. Once the deductible is met, Medicare provides an 80% coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. coverage for their outpatient costs.2Medicare.gov, “Part B costs“, Accessed September 9, 2021
For Medicare Advantage plan members, the costs for outpatient care vary from plan to plan. Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). must provide the same benefits as Medicare Part A and Part B, but they are allowed to set their own deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share. and copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service.. In most cases, plan members will be required to use the plan’s network of providers. For non-emergency care, prior approvalPrior authorization is a process used by health plans to control healthcare costs. Most HMO plans and some PPO plans require authorization before receiving certain treatments, medical services, or prescription drugs. may be required.3Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed September 9, 2021
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.4Medicare.gov, “Outpatient hospital services“, Accessed September 9, 2021
If a beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. 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 coverage5Medicare.gov, “Inpatient hospital care“, Accessed September 9, 2021.
Citations
- 1Cigna.com, “What is Inpatient vs. Outpatient Care“, Accessed September 9, 2021
- 2Medicare.gov, “Part B costs“, Accessed September 9, 2021
- 3Medicare.gov, “How do Medicare Advantage Plans work?“, Accessed September 9, 2021
- 4Medicare.gov, “Outpatient hospital services“, Accessed September 9, 2021
- 5Medicare.gov, “Inpatient hospital care“, Accessed September 9, 2021