What is Outpatient Care?

What Do I Pay?

Male patient sitting on exam table in clinic room
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Outpatient care, sometimes called ambulatory care, describes medical care or treatment that does not require an overnight stay in a hospital or medical facility. Outpatient care may be administered in a medical office or a hospital, but most commonly, it is provided in a medical office or outpatient surgery center.

Outpatient care can include routine services such as check-ups or visits to clinics.

Even more involved procedures such as surgical procedures, so long as they allow you to leave the hospital or facility on the same day, can still be considered as outpatient care. Many surgical services, rehabilitation treatments, as well as mental health services are available as outpatient services. Outpatient care tends to be less expensive than inpatient care since it is often less involved and does not require a patient's continued presence in a facility, which uses up less of the hospital or medical clinic's resources.

For the purposes of insurance, most outpatient care is broken out based on the type of service provided (Primary Care Physician, Specialist, Mental Health, etc.). Outpatient surgery is one area that is specifically identified, and describes your share of costs should you need a procedure or operation that does not require overnight admission at the facility. Like inpatient treatments, the costs associated with the facility itself and the physician/surgeon performing the procedure are often treated as two different coverage benefits.

Medicare: Outpatient Vs. Inpatient

If you have Medicare, you should ask whether or not you are considered inpatient or outpatient. Your hospital status (whether the hospital considers you an “inpatient” or “outpatient”) affects how much you pay for hospital services (like X-rays, drugs, and lab tests) and may also affect whether Medicare will cover care you get in a skilled nursing facility (SNF) following your hospital stay.

 

  • You’re an inpatient starting when you’re formally admitted to a hospital with a doctor’s order. The day before you’re discharged is your last inpatient day.
  • You’re an outpatient if you’re getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit you to a hospital as an inpatient. In these cases, you’re an outpatient even if you spend the night at the hospital. 

Medicare: What You Pay as an Outpatient

Part B covers outpatient hospital services. Generally, this means you pay a copayment for each individual 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 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. 

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