Does Medicare Part A Cover Outpatient Surgery?

Part A is the part of Medicare that pays for inpatient care you get during a stay in the hospital. Part A benefits are also available for multiday stays in various inpatient and residential care centers. This benefit does not usually pay for outpatient procedures, which mostly fall under the umbrella of Part B coverage.

What Are the Parts of Medicare?

People who are new to Medicare can easily get lost in the multiple different plans, parts and other divisions of coverage they have to navigate. Medicare benefits, which automatically become available when an eligible beneficiary reaches age 65 or develops a disabling long-term medical condition, are grouped according to how they are delivered. Fortunately, this splits the program into three relatively easy to remember parts: A, B and D.

What Does Medicare Part A Cover?

Medicare Part A is the hospital inpatient benefit. It also covers qualified stays in residential treatment facilities, including some drug and alcohol rehab providers. Part A benefits automatically kick in for all eligible U.S. citizens who reach age 65, or who have been disabled long enough to collect SSDI for six continuous months. Part A benefits are provided with no monthly premium for beneficiaries who have earned sufficient credits through work. This part of Medicare pays for most of the cost of treatment in an inpatient setting, which is defined by admission to a medical facility where you stay for two consecutive nights, from midnight to midnight.

What Does Medicare Part B Cover?

Medicare Part B is the outpatient coverage option. Unlike Part A, you do not automatically get signed up for Part B when you turn 65. Instead, you generally have to sign up for a Part B plan with a premium and deductible you like. Part B pays much of the cost for almost all outpatient care services. This includes medical office visits, transportation, durable medical supplies, bandages and other disposables, and most outpatient surgeries.

What Does Medicare Part D Cover?

Medicare Part D is the prescription drug benefit. This part of Medicare pays much of the cost of the prescription medications your doctor prescribes.

Medicare Advantage

Medicare Part C is sometimes called Medicare Advantage, because it is a fundamentally different way to receive your Medicare benefits. Unlike Original Medicare, Medicare Advantage does not divide its coverage areas into separate parts. Instead, Part C combines all of the coverage beneficiaries usually get from both Parts A and B into a privately provided insurance plan. Often, these plans include some prescription drug coverage and non-Medicare items, such as vision and dental care. If you get your Medicare benefits through a Medicare Advantage plan, your outpatient expenses are almost certainly covered by the same plan that pays for your inpatient care in a hospital.

Which Parts of Medicare Pay for Medical Procedures?

Which part of Original Medicare pays for what procedures is broadly easy to summarize, but the details can get complicated. As a rule, all of the treatments you get during a multiple-night stay in the hospital fall under Part A, while outpatient treatments, including surgery, are covered by Part B. There are exceptions to these rules:

Emergency room visits are generally billed to Part B, outpatient treatment, even if you are held overnight in the ER.
Hospital care after admission through the ER may also be billed as a Part B service if your stay in the hospital is short enough; generally less than two consecutive midnights.
A procedure that is normally done on an outpatient basis, such as nail clipping for people with diabetes, might be billed as an inpatient service if you are already in the hospital for an unrelated matter, such as an invasive surgery.

Costs Not Covered by Medicare

Even if your outpatient procedure is paid for by Medicare, you might still owe some money as a co-payment or as a deductible. In these cases, you must pay any balance you owe before Medicare can assist with the rest of the bill. If you have a Medicare supplemental policy, which is a private insurance plan designed to work alongside your regular Medicare benefits, you must still pay for any unshared costs, after which Medicare benefits kick in and unpaid balances fall under your Medigap policy.

Get Extra Help With Outpatient Costs

If you have an outpatient procedure planned but are not sure how to pay for benefits your Medicare Part B plan doesn’t cover, you have several options for extra help. One of the most popular choices for seniors with low income is to add Medicaid as a supplemental policy to your benefits. Unlike Medicare, Medicaid plans do not generally split their coverage between inpatient and outpatient services. Instead, in most states, your necessary medical care is eligible for coverage on a licensed practitioner’s authorization. If you have both Medicare and Medicaid, your Medicare benefits are billed first, with Medicaid picking up the unpaid remainder.

Even with both Medicare and Medicaid, you might still have a share of cost attached to the outpatient procedure you need. If you have time to investigate different providers before your procedure, and if your healthcare network permits out-of-network care, you can choose a provider that offers reduced fees for seniors and people with limited means to pay. Many university and public hospitals offer steeply discounted care for people who need it, and many keep indigent care funds to help people pay some of the uncovered costs of various medically necessary procedures. These discounts and subsidies are generally compatible with your Medicare Parts A and B benefits, and most are compatible with any authorized Part C plan you may have.

FAQ

What Does Part A Pay For?

Part A benefits pay for inpatient care in hospitals and residential care facilities

Which Part of Medicare Pays for Outpatient Care?

Most outpatient procedures fall under Medicare Part B benefits. Medicare Advantage plans include Part B benefits, and so they also offer the same coverage.

How Do I Pay for Outpatient Procedures with Medicare Part B?

Providers that are authorized to bill Medicare for outpatient services can directly invoice the program. Present your Medicare benefits card, or the ID card your Medicare Advantage plan sent you, at the time of payment.