Does Medicare Pay for Outpatient Surgery?

Outpatient surgery is a common medical procedure. Medicare generally provides coverage for outpatient surgical services, but the extent depends on several factors. Understanding how Medicare covers these procedures and potential patient financial responsibilities can help beneficiaries navigate their healthcare decisions.

Medicare Parts Covering Outpatient Surgery

Medicare Part B covers most outpatient surgical services. This includes physician services, such as the surgeon’s and anesthesiologist’s fees, and facility fees for services performed in a hospital outpatient department or an Ambulatory Surgical Center (ASC). Part B also covers related diagnostic tests, medical supplies, and follow-up care.

Medicare Part A primarily covers inpatient hospital stays and related services. If an outpatient surgery leads to an inpatient admission, Part A may cover facility costs incurred after the official inpatient admission. The classification of a patient’s status as either inpatient or outpatient is determined by the hospital and is crucial for understanding how Medicare will cover the associated costs.

Medicare Advantage Plans (Part C) are offered by private insurance companies approved by Medicare. These plans are required to provide at least the same level of coverage as Original Medicare, which includes Parts A and B. While Medicare Advantage plans cover outpatient surgery, they may have different cost-sharing structures, network requirements, and additional benefits beyond Original Medicare.

Medicare Part D, which provides prescription drug coverage, does not cover the surgical procedure itself. However, Part D may cover medications prescribed after discharge that are related to the surgery. This ensures that beneficiaries have assistance with necessary prescriptions for their recovery.

Patient Financial Responsibilities for Outpatient Surgery

Beneficiaries with Original Medicare face specific out-of-pocket costs for outpatient surgery. Medicare Part B has an annual deductible that a beneficiary must pay before Medicare covers services. For 2024, this deductible is $240.

After the deductible is met, Medicare Part B pays 80% of the Medicare-approved amount for outpatient surgical services. The beneficiary is responsible for the remaining 20% as coinsurance. This coinsurance applies to both the facility fees and the professional fees.

Some services, particularly under Medicare Advantage plans or for specific facility types, may involve fixed copayments rather than coinsurance. Medicare Supplement (Medigap) plans can help cover out-of-pocket expenses, such as deductibles and coinsurance. Medicare Advantage plans may also structure costs differently, offering fixed copayments per service and including out-of-pocket maximums.

Commonly Covered Outpatient Surgical Procedures

Medicare covers medically necessary outpatient surgical procedures performed in an approved setting. Approved settings include hospital outpatient departments and Ambulatory Surgical Centers (ASCs). Medical necessity means a doctor recommends the procedure to diagnose or treat a medical condition.

Common examples of covered outpatient surgical procedures include cataract removal, colonoscopies, certain orthopedic procedures like knee arthroscopy, hernia repair, and minor skin procedures. Medicare also covers some pain management injections when medically indicated.

For a procedure to be covered, it must be medically necessary, ordered by a physician, and listed on Medicare’s approved list for outpatient settings. Procedures not covered include those considered not medically necessary, such as cosmetic surgery (unless medically required), experimental procedures, or those performed in unapproved settings.

Steps to Confirm Outpatient Surgery Coverage

Before outpatient surgery, verify coverage and understand potential costs. Confirm that the surgeon, anesthesiologist, and facility (hospital outpatient department or Ambulatory Surgical Center) accept Medicare assignment. When a provider accepts Medicare assignment, they agree to accept the Medicare-approved amount as full payment, limiting out-of-pocket expenses to deductibles and coinsurance.

Beneficiaries should request a detailed cost estimate from their provider or the facility where the surgery will take place. This estimate should include Medicare’s estimated payment and the patient’s estimated out-of-pocket share for all services, including facility and professional fees. Understanding these estimates in advance can help prepare for financial responsibilities.

Contacting Medicare or your Medicare Advantage plan is another important step to confirm coverage. For Original Medicare, call 1-800-MEDICARE to inquire about coverage and expected costs. If you have a Medicare Advantage plan, contact your plan directly for details on coverage rules, network requirements, and cost-sharing.

Determine if prior authorization is required for the planned procedure, especially with Medicare Advantage plans. Some procedures may require prior approval from the plan before they are performed to ensure coverage. Maintaining thorough records of all communications, cost estimates, and documentation related to the surgery is also recommended.

After surgery, beneficiaries should review their Explanation of Benefits (EOB) statement. The EOB details the services received, the amount billed, what Medicare paid, and the amount the beneficiary owes, allowing for verification of correct billing and coverage application. This proactive approach helps ensure a smoother experience and reduces the likelihood of unexpected financial burdens.