Original Medicare is divided into two parts. They are: Medicare Part A and Medicare Part B.
Medicare Part A mainly provides coverage for inpatient services such as services that take place in hospitals and skilled nursing facilities.
Meanwhile, Medicare Part B provides coverage for outpatient services that take place in outpatient settings like the doctor’s office and more.
So a common question many people have is, “does Medicare Part A cover outpatient surgery?” In this article, we answer that question in clear, plain English.
Does Medicare Part A Cover Outpatient Surgery?
The short answer is no. In most cases, Medicare Part A does not cover the cost of outpatient surgery.
What Does Medicare Part A Cover?
Medicare Part A does not provide coverage for outpatient surgery. But what does it cover?
Well, Medicare Part A only covers inpatient services (including surgery) that take place in an inpatient setting such as hospitals. This includes stays at traditional hospitals but also stays at similar facilities such as:
- Acute care hospitals
- Long-term care hospitals
- Critical access hospitals
- Inpatient rehab facilities
- Inpatient psychiatric facilities
Part A also covers the following:
- Stays in a skilled nursing facility
- Care at a nursing home (this is for inpatient care in a skilled nursing facility but excludes custodial or long-term care)
- Home health care
- Hospice care
For a stay at an inpatient facility, Medicare Part A will cover 100 percent of the hospital-specific costs for stays for up to 60 days. From days 61 to 90, Medicare Part A will still provide coverage. However, you will pay a deductible during that time.
After 90 days, Medicare Part A will no longer provide coverage. However, Medicare Part A does provide 60 lifetime reserve days. If you have them, they will still provide coverage for your hospital stay after 90 days, but, again, you will be responsible for a deductible.
Medicare Part B
On the other hand, Medicare Part B provides coverage for outpatient surgery. For Medicare Part B to provide coverage, the outpatient surgery must also be medically necessary and ordered by your healthcare provider.
Once approved, coverage for outpatient surgery is provided by Medicare Part B. Once approved, Medicare Part B covers 80 percent of the costs of bypass surgery. You will pay for the remaining 20 percent.
Medicare Part C
Medicare Advantage plans (Medicare Part C) also provide coverage for outpatient surgery. They cover everything Original Medicare covers, as well as some additional benefits. However, exactly what Advantage plans cover and how much your out-of-pocket costs will vary depending on your plan.
Medicare Part C plans that include prescription drug plans will also provide coverage for medications that your healthcare provider will prescribe to you.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”