Outpatient Hospital Services, Specialty Care, and Behavioral Healthcare Services

We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include, but are not limited to:

• Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery
• Laboratory and diagnostic tests billed by the hospital
• Mental health care, including 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 such as splints and casts
• Certain drugs and biologicals that you can’t give yourself

*Prior authorization and referral rules may apply. Please refer to your plan’s Evidence of Coverage for more information.

Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an outpatient. If you are not sure if you are an outpatient, you should ask the hospital staff.

Covered services include:

Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, licensed professional counselor (LPC), licensed marriage and family therapist (LMFT), nurse practitioner (NP), physician assistant (PA), or other Medicare-qualified mental health care professional as allowed under applicable state laws.

*Prior Authorization and referral rules may apply. Please refer to your plan’s Evidence of Coverage for more information.

Covered services include: physical therapy, occupational therapy, and speech language therapy.

Outpatient rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs).

*Prior Authorization and referral rules may apply. Please refer to your plan’s Evidence of Coverage for more information.