The number of outpatient surgeries was 129 million in 2018 and is expected to grow to 144 million by 2023. If you’re one of the millions who need surgery this year, you might wonder if your Medicare coverage applies.
Does Medicare Part A cover outpatient services? Many people know Medicare Part A as “hospital insurance,” so it’s common to think that outpatient surgery is covered under this section.
However, when you look at what outpatient surgery is, you’ll see that it’s more like a doctor visit than an inpatient stay.
Let’s take a look at outpatient services and how they are covered by Medicare.
What is Outpatient Surgery?
When you get surgery you stay in the hospital, right? Not anymore. Outpatient surgery is very common for many procedures.
What is outpatient health care? With an outpatient procedure, you’re able to leave the hospital the same day. Advances in medical processes and medication are making that more possible than it’s ever been.
When you have outpatient surgery, you’ll be monitored in a care unit as you wake up from anesthesia. When you can perform a variety of simple tasks, including using the restroom, you’ll be discharged.
You cannot drive yourself home after an outpatient procedure. You’ll need to have someone drive you home and stay with you for 24 hours to ensure there aren’t any complications.
Coverage for Outpatient Surgery With Original Medicare
Because you’re not staying in the hospital for one or more nights, the surgery isn’t considered an inpatient service. That means that it’s not covered under Medicare Part A.
Instead, you’ll find coverage under Medicare Part B. This part also covers other medically necessary services and preventive care.
Keep in mind that the outpatient surgery must be medically necessary in order to have coverage from Original Medicare. You will pay your Part B deductible and the 20% copayment and Medicare will cover the rest.
There is no annual limit to out-of-pocket expenses with Original Medicare, so costs can add up quickly.
Outpatient Hospital Services Coverage With Medicare Advantage
Another way to use Medicare to cover your health needs is with Medicare Advantage. These plans are administered by private health insurance companies. They are an all-in-one replacement of Original Medicare.
Depending on your plan, your out-of-pocket costs for an outpatient surgery could be much less than with Original Medicare. For instance, you may pay a set copayment instead of a percentage.
Another advantage is that many Medicare Advantage plans have an annual maximum out-of-pocket limit. Once you hit that limit, your care is covered 100%.
Keep in mind that Medicare Advantage plans generally have a specific list of approved medical providers and outpatient services in hospitals might require preauthorization.
Find the Coverage You Need for Outpatient Services
Medicare helps you with medically necessary outpatient services. However, this coverage is found under Part B rather than Part A of Original Medicare.
If you have a different type of plan, such as Medicare Advantage, you may have more benefits. However, outpatient professional services may need preauthorization before they can move forward.
If you’re ready to sort through the Medicare options and choose the right plan for you, we’re here to help.