Perhaps your doctor has recommended outpatient surgery for you as treatment for a health condition. Among your questions, you may wonder how much it will cost you.

What is outpatient surgery?

Outpatient surgery refers to a surgical procedure a doctor performs without admitting the patient into the hospital. The setting for an outpatient surgery may be in the doctor’s office, in an ambulatory or outpatient surgical center, or in a hospital. When you’re in a hospital, you’re not considered an inpatient unless a doctor has admitted you.

Does Medicare cover outpatient surgery?

Medicare Part B (medical insurance) generally covers certain outpatient surgeries as long as they meet two requirements:

  • Your doctor must consider the surgical procedure “medically necessary.”
  • The doctor(s) performing the surgery must accept Medicare assignment (that is, the doctor agrees to accept the Medicare-approved amount for the service, and not bill you besides a copayment or coinsurance amount).

What does Medicare pay for approved outpatient surgery?

Medicare Part B typically pays 80% of the Medicare-approved amount for the services of the outpatient surgery center and for the doctors who perform the outpatient surgery, after you have met the annual Medicare Part B deductible.

What can you expect to pay for an approved outpatient surgery?

If you have Medicare Part B, you can expect to pay 20% of the Medicare-approved amount for the outpatient surgery center and doctors’ charges. The Medicare-approved amount varies depending upon the outpatient surgery procedure you receive. You may want to ask your doctor and the outpatient surgical facility about their fees for your outpatient surgery to get an idea of your estimated out-of-pocket costs. Remember you might have to pay the annual Medicare Part B deductible before Medicare coverage begins.

What else should I know about Medicare and outpatient surgery?

How much you pay might also be affected by other factors, such as:

  • If you have outpatient surgery in a hospital, Medicare generally will pay its portion of the non-physician hospital services, and you will be responsible for paying the Medicare deductible or copayment.
  • If Medicare considers the outpatient surgery a preventive service, Medicare Part B might cover the service at 100% of the Medicare-approved amount.
  • If you have a Medicare Supplement (Medigap) plan, it may help pay your out-of-pocket costs for outpatient surgery. Different Medicare Supplement plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles. You may contact the plan’s customer service for benefit information that is specific to your outpatient surgery.
  • If you are enrolled in a Medicare Advantage plan, the plan is required to offer at least the same coverage as Medicare Part A and Part B provide. However, Medicare Advantage plans may have different deductibles, coinsurance, and copayment amounts than Medicare Part A and Part B. Consult your Medicare Advantage plan’s customer service for details of how it covers your outpatient surgery.
  • Remember, you may want to use doctors, hospitals and outpatient surgery centers that accept Medicare assignment. Otherwise, you might pay in full regardless of whether or not the outpatient surgery is medically necessary.

Do you have other questions about outpatient surgery and Medicare coverage? I would like to help you.

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