Medicare Coverage for Outpatient (Ambulatory) Surgery

What is outpatient (ambulatory) surgery?

Outpatient (ambulatory) surgery is surgery done without staying in the hospital overnight. It may be done in:

• a special section of a hospital
• a doctor's office or clinic
• a surgical center.

After outpatient surgery, you can usually go home in 2 to 4 hours.

What is Medicare?

Medicare is:

• a federal health insurance program
• for people over age 65
• for people under age 65 who are disabled in certain ways.

Your local Social Security office can answer your questions about signing up for Medicare and can enroll you in the program.

Rules about what Medicare does and does not cover can be hard to understand. They also change from time to time. The amount of money you are expected to pay for Medicare coverage (premiums) can change every January. The amount you must pay first before Medicare begins to pay (deductibles) and the portion of costs you must pay (copayments) may also change.

In most cases, both you and the Medicare program pay toward the cost of your medical services.

Some people think of Medicare as two health insurance programs: Medicare Part A and Medicare Part B. Each part covers different services. Both parts pay toward costs for services considered necessary for medical reasons.

Medicare Part A (sometimes called "the hospital part of Medicare") pays most of inpatient hospital care and hospice care. Under certain conditions, it pays for up to a couple months of care in a skilled nursing facility. Medicare Part A and Medicare Part B both pay toward home health care if certain conditions are met.

Medicare Part B (sometimes called "the doctor part of Medicare") pays part of the cost of some medical services and supplies.

Does Medicare cover outpatient surgery?

Outpatient surgery is covered under Part B of Medicare.

• Medicare covers surgery to diagnose or treat an illness or injury, if the surgery is medically necessary.
• Medicare pays 80% of the approved charges. You must pay the remaining 20%, after you meet your yearly deductible.
• If your doctor accepts Medicare assignment, it means that he or she agrees to accept as payment in full the amount Medicare agrees to pay for that surgery.

If your doctor does not accept Medicare assignment:

• If the bill is for more than the amount Medicare pays, you will owe the rest.
• If your surgery is not an emergency the surgeon must give you a written estimate of the charges.
• The doctor must tell you if he or she thinks Medicare will judge the surgery to be medically necessary.

For more information, call Medicare toll-free at 1-800-638-6833.