Yes. Medicare Part B generally covers outpatient surgery when it’s medically necessary. Your coverage and costs depend on the surgery, where you get care and the type of Medicare coverage you have.
Learn what Medicare covers and what to check before your surgery.
What do I need to know about Medicare coverage for outpatient surgery?
Here are a few important things to know:
- Medicare Part B generally covers medically necessary outpatient surgery.
- Covered services can include doctor services, facility services and anesthesia.
- Your costs and coverage requirements depend on the surgery, where you get care and the type of Medicare coverage you have.
- Before a nonemergency surgery, check your coverage and any requirements that apply.
What is outpatient surgery?
Outpatient surgery is a procedure that usually lets you go home the same day without being admitted to the hospital as an inpatient.
It can take place in a hospital outpatient department, a doctor’s office or an ambulatory surgical center (ASC). In some cases, you may stay overnight for observation and still be an outpatient.
What is the difference between outpatient and inpatient surgery?
The main difference is whether you are formally admitted to the hospital as an inpatient.
- Outpatient surgery: You have surgery without a formal inpatient admission.
- Inpatient surgery: You are formally admitted to the hospital for your surgery.
Inpatient hospital care generally falls under Medicare Part A. Outpatient hospital services generally fall under Medicare Part B. Your inpatient or outpatient status can affect what you pay.
What outpatient surgery services does Medicare cover?
Medicare Part B can cover medically necessary outpatient surgery and related care, including:
- Hospital outpatient services and supplies.
- Services at an outpatient surgery center, such as nursing care and use of operating and recovery rooms.
- Care from your doctor before, during and after surgery.
- Anesthesia and other medical services for the procedure.
Does Medicare Part A cover outpatient surgery?
No. Medicare Part A generally does not cover outpatient surgery.
Part A usually applies after you are formally admitted to the hospital as an inpatient.
If you are admitted as an inpatient after surgery, Part A can apply to your inpatient hospital care.
Do Medicare Advantage (Part C) plans cover outpatient surgery?
Yes, your costs and plan requirements can vary.
Before surgery, check if your surgeon and facility are in network.
Also check if you need prior authorization or a referral. Review your plan documents before scheduling a nonemergency surgery.
If you are an Aetna® Medicare member, find providers that accept your plan.
How can I find out if Medicare covers my outpatient surgery?
To check your coverage:
Ask your doctor if the surgery is medically necessary.
Confirm that the surgery will be outpatient.
Check whether you need prior authorization or a referral.
If your plan uses a provider network, check that both your surgeon and facility are in-network.
Review your coverage and what you may pay before the surgery.
If you have an Aetna Medicare plan, you can:
How much does outpatient surgery cost with Medicare?
It varies. Your costs depend on the surgery, where you get care, your provider and the type of Medicare coverage you have. With Original Medicare, you pay the Part B deductible first. A deductible is what you pay for covered services before Medicare starts to pay.
After that, you generally pay 20 percent coinsurance for health care provider services. Coinsurance is your share of the cost.
You can also have a copay for services in a hospital outpatient setting. A copay is a set amount you pay for a covered service. Costs can differ between a hospital outpatient department and an ASC.
What should I know before and after outpatient surgery?
Use these checklists to help you plan for your surgery and recovery.
Before your surgery
- Review the instructions from your doctor and care team.
- Ask if you need prior authorization or a referral.
- Check that your surgeon and facility are in network.
- Ask where your surgery will take place and confirm that it will be outpatient.
- Ask what you may pay for the surgeon, facility and anesthesia.
- Ask if you will need follow-up visits, therapy or other care.
- Plan for transportation home and any help you may need during recovery.
After your surgery
- Check your coverage for any medical equipment you may need, such as a walker or wheelchair.
- Check your coverage for physical therapy or rehabilitation.
- Check how your post-surgery medicines are covered. Some drugs may be covered under Medicare Part B while others may be covered through Medicare drug coverage.
- Review your claims and bills. Contact your plan if a charge or coverage decision is unclear.
Common questions about outpatient surgery
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It depends. Prior authorization depends on the surgery and type of Medicare coverage.
Before a nonemergency surgery, ask your provider about prior authorization and check your plan.
If you have an Aetna Medicare plan, learn more about prior authorization. -
It depends on the drug and where you get it. Medicare Part B covers some drugs you get in an outpatient setting.
Part D can cover some prescriptions that Part B does not cover.
If you are an Aetna Medicare member, check your plan’s drug list. -
It depends on your Medicare Advantage plan.
With an HMO plan, you generally need to use in-network providers for non-emergency services.
With a PPO plan, you can generally get out-of-network care from providers who accept the plan.
You may pay more for out-of-network care. Before scheduling surgery, check that both your surgeon and facility are in network for your plan.
Learn more about Medicare HMO and PPO plans -
Yes, in some cases. Medicare Part B can cover a second opinion before medically necessary, nonemergency surgery.
Medicare can also cover a third opinion if the first and second opinions are different. -
No. Medicare coverage depends on the surgery and whether Medicare requirements are met.
Before a nonemergency surgery, ask your doctor and check your Medicare coverage to see if the procedure is covered.
