Medicare 2026

Hospital Outpatient Bills Under Medicare: How the Facility Copay and Its Per-Service Cap Work

Getting care at a hospital outpatient department can be convenient — labs, imaging, infusions, minor procedures, and specialty visits are often done there. But the way Medicare bills for that care is different from a visit to an independent doctor's office, and the difference can show up on your Explanation of Benefits. Here is a plain-English look at how facility copayments work under Original Medicare, where the per-service cap applies, and what to watch for.

Two bills for one visit

When you receive care in a hospital outpatient department under Original Medicare, two things usually happen on the billing side. First, the physician bills Part B, and you generally owe 20 percent of the Medicare-approved amount for the doctor's professional services. Second, the hospital bills Part B separately for the facility — the room, staff, supplies, and overhead — and you owe a copayment to the hospital for each service you receive. The Part B deductible applies before Medicare starts paying its share. Certain preventive services are an exception: they carry no copayment, and the deductible does not apply.

That second bill — the facility copayment — is what often surprises people who are used to a single charge at an independent doctor's office.

The per-service cap, and why your total can still be higher

There is a protection built in. In most cases, the hospital copayment for a single outpatient service cannot be more than the Part A inpatient hospital deductible, which is $1,736 in 2026. So no single outpatient service in a typical hospital setting should leave you with a facility copay larger than that figure.

Important nuance: that cap applies per service. If you have several outpatient services on the same day — say, a visit, a couple of tests, and a procedure — each one can carry its own copayment, and together they can add up to more than the Part A deductible amount.

There is also an exception for critical access hospitals. At these facilities, the outpatient copayment may be higher and may exceed the Part A hospital stay deductible, so the usual cap does not necessarily apply.

Why the same care can cost more at a hospital

Because of the facility copayment, the same service often costs more when it is performed in a hospital outpatient department (or a clinic owned by a hospital) than when it is performed in a doctor's office that is independent of the hospital. A simple EKG is a classic example: done in an independent office, you typically owe the Part B coinsurance for the professional service; done at a hospital or hospital-owned clinic, there is an additional facility copayment.

If you have a choice of setting for a non-emergency service, it can be worth asking whether a clinic is hospital-owned or independent, and what each setting would cost. Price transparency rules require hospitals to post the standard charges for all of their items and services on a public website, and Medicare.gov's Procedure Price Lookup tool provides cost estimates for common outpatient procedures done in hospital outpatient departments and ambulatory surgical centers.

Ambulatory surgical centers

Ambulatory surgical centers (ASCs) are a separate setting with their own payment rules. With Original Medicare at an ASC, you generally pay 20 percent of the Medicare-approved amount to the center and 20 percent to the doctor, after the Part B deductible. Certain preventive services are again the exception. For many procedures that can be safely done outside a hospital, ASC billing works out differently from hospital outpatient billing — another reason to check the Procedure Price Lookup before you schedule.

A 2026 change for drug administration in certain hospital clinics

Starting in 2026, Medicare pays the lower physician fee schedule-equivalent rate for drug administration services furnished in certain off-campus hospital outpatient departments — those "excepted" from section 603 of the Bipartisan Budget Act of 2015 — with an exemption for rural sole community hospitals. In its 2026 final rule, CMS estimated this policy would save people with Medicare about $70 million in coinsurance in 2026. If you receive infusions or injections at a hospital-affiliated clinic, your coinsurance for the administration portion of that care may be lower than it was before.

How this fits into your bigger picture

Original Medicare on its own has no annual out-of-pocket maximum, which is why many people pair it with a Medigap policy to help cover coinsurance and copayments, or choose a Medicare Advantage plan that bundles coverage with its own cost-sharing rules and network. Each path has trade-offs — predictability, provider choice, extra benefits, premiums, and rules about referrals and networks — and the right fit is personal. This article is educational and does not recommend one approach over another.

A few program dates and figures worth keeping in mind as you plan for next year: Annual Enrollment for 2027 coverage runs October 15 through December 7, 2026, with changes taking effect January 1, 2027. The Part D out-of-pocket cap is $2,100 in 2026 and will be $2,400 in 2027, and the most any Part D plan may charge as a deductible in 2027 is $700. Social Security announced a 3.6 percent cost-of-living adjustment for benefits payable beginning January 2027. The 2027 Part B standard premium and deductible, along with the IRMAA income-related surcharges, have not yet been announced; CMS releases those figures in the fall, usually in November.

People with Medicaid or Extra Help have a monthly Special Enrollment Period to move to Original Medicare with a stand-alone Part D plan or to switch stand-alone plans, and full-benefit dual-eligible individuals can join an integrated D-SNP in any month.

Where to go next

For official details on outpatient costs, price-estimate tools, and enrollment, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Before scheduling an outpatient service, consider checking the Procedure Price Lookup and the hospital's posted standard charges so there are fewer surprises on the bill.