Does Medicare Part A Cover Outpatient Surgery?

For over 50 years, Medicare has been providing health insurance coverage for Americans age 65 and older. Providing approximately half of the healthcare expenses of nearly 58 million beneficiaries, Medicare is fulfilling the proposal originally introduced by President Eisenhower.

Medicare is comprised of two primary coverages, Part A and Part B. Services not covered under either part are either paid for out-of-pocket or through private insurance. For example, most dental, eye, and foot care are not covered by Medicare, along with a number of other services.

Whether or not Medicare Part A covers outpatient surgery is a common question. The reason the question pops up so often is that the official Medicare website does not specifically mention outpatient surgery under either Part A or Part B. Today we clarify which part covers this important service.

Part A

The first part of Medicare can be best described as hospital or inpatient care. As such, outpatient surgery would not be covered under Part A. Instead, Medicare Part A generally covers:

• Hospice care
• Home health care
• Inpatient care (in a hospital)
• Skilled nursing care provided in a facility
• Inpatient care provided in a skilled nursing facility

The processing of Medicare claims is handled at the local level. This means decisions are made by area companies who decide medical necessity and whether a service is covered where you live. To be certain if your inpatient or hospital services are covered, ask your physician or visit the government’s official website at Medicare.gov.

Part B

Medicare Part A is designed to cover services received while staying overnight in a skilled nursing facility or hospital. Part B, on the other hand, works to pay for the other medical services you need.

The official Medicare website states Part B covers medically necessary and preventative services including:

• Clinical research
• Ambulatory services
• Durable medical equipment
• Second opinions before surgery
• Outpatient prescription drugs (limited)
• Mental health (inpatient, outpatient, and hospitalization)

Not specifically listed is outpatient surgery. Herein lies the confusion, many beneficiaries have when it comes to determining if their outpatient surgery will be covered on not.

Fortunately, the government expands upon those services covered when defined as medically necessary. As an outpatient, Medicare Part B will cover:

• Laboratory tests
• Medical supplies
• X-rays and radiology services
• Preventative and screening services
• Certain drugs and biologicals (very limited and further defined)
• Emergency or observation services including same-day surgery
• Mental health care in a partial hospitalization program (limitations apply)

Same-day surgery that occurs in an outpatient facility are indeed covered, although the surgery is covered under Part B, not Medicare Part A. Part B may also pay even if you spend the night in the hospital if your physician did not write an order to be admitted.

Making Sure You Are Covered

Even though Medicare has been around for half a decade, determining exactly what services are covered is still a complex endeavor. To learn more about Medicare and additional insurance options, contact the experts at MedicareHealthInsuranceFacts.com  at (877) 829-1109. Our licensed insurance experts will be happy to answer any questions you have.