Does Medicare A Cover Outpatient Surgery?
Understand how Medicare covers outpatient surgery. Learn which part of Medicare applies, what your costs are, and how to prepare.
Medicare is a federal health insurance program for individuals aged 65 or older, along with certain younger people who have specific disabilities or End-Stage Renal Disease. This article clarifies how Medicare provides coverage for outpatient surgery, distinguishing between different parts of the program and outlining potential patient responsibilities.
Understanding Medicare Part A and Outpatient Services
Medicare Part A, known as Hospital Insurance, is primarily intended to cover services related to inpatient hospital stays. This includes costs for skilled nursing facility care, hospice care, and certain home health services. Medicare Part A does not cover outpatient surgery. Outpatient services refer to medical care received without requiring an overnight stay in a hospital or medical facility. This distinction between inpatient and outpatient status impacts how Medicare covers the associated costs.
Medicare Part B and Outpatient Surgical Coverage
Medicare Part B, which is Medical Insurance, is the component of Medicare that covers outpatient surgery. Part B covers a broad range of medically necessary services and supplies not covered by Part A. Coverage under Part B includes doctor’s services, outpatient hospital care, and services provided at ambulatory surgical centers (ASCs).
Outpatient surgical procedures such as cataract removal, hernia repairs, and knee arthroscopy are covered under Medicare Part B, provided they are deemed medically necessary by a doctor. These procedures are performed in hospital outpatient departments or freestanding ambulatory surgical centers. Part B coverage extends to the facility fees for the surgical center and the professional services rendered by the doctors performing the surgery, including anesthesia and follow-up care.
Patient Costs for Outpatient Surgery
Out-of-pocket costs for outpatient surgery under Medicare Part B involve a deductible and coinsurance. For 2025, the annual Medicare Part B deductible is $257, which must be met before Medicare begins to pay its share for covered services. This deductible applies once per year, covering various Part B services.
After the annual deductible is satisfied, patients are responsible for a coinsurance amount. This coinsurance is 20% of the Medicare-approved amount for the outpatient surgery center services and the doctors’ fees. The specific dollar amount can vary depending on the Medicare-approved amount for the procedure and the facility type (hospital outpatient department or ambulatory surgical center).
Preparing for Outpatient Surgery
Individuals preparing for outpatient surgery under Medicare should confirm that Medicare Part B coverage is active before the procedure. Verifying coverage status can prevent unexpected financial burdens. Patients should also confirm that their healthcare provider and the surgical facility, whether a hospital outpatient department or an ambulatory surgical center, accept Medicare assignment.
When a provider accepts Medicare assignment, they agree to accept the Medicare-approved amount as full payment for services, which limits the patient’s out-of-pocket costs to the deductible and coinsurance. Additionally, it is advisable to inquire whether prior authorization is required for the specific surgical procedure. Discussing all aspects of the surgery, including estimated costs, with the doctor and the facility beforehand can provide clarity on financial responsibilities.