Medicare covers most outpatient surgery, but you pay a share of the cost

Yes, Medicare Part B covers outpatient surgery performed in a hospital or surgical center. You do not need to be admitted overnight for Medicare to pay its share. However, you will owe a copay, coinsurance, or both — the exact amount depends on where the surgery happens and what procedure you have.

Outpatient surgery means you go home the same day. Medicare calls this "ambulatory surgery." Part B pays 80% of the approved amount after you meet your annual deductible. You are responsible for the other 20%, plus any costs above what Medicare approves.

Key Takeaways

  • Medicare Part B covers outpatient surgery at hospitals and surgical centers, paying 80% of the approved cost after your deductible.
  • You owe 20% coinsurance plus your annual Part B deductible ($240 in 2024) before Medicare starts paying.
  • The facility where surgery happens — hospital outpatient department versus independent surgical center — affects your out-of-pocket costs.
  • You should ask your surgeon's office what Medicare approves for your specific procedure and request an estimate of what you will owe.
  • If you have a Medigap or Medicare Advantage plan, your out-of-pocket costs may be lower than Original Medicare alone.

How Medicare Part B pays for outpatient surgery

When you have outpatient surgery, Medicare Part B covers the surgeon's fee, anesthesia, and facility charges. The payment works the same way as other Part B services: Medicare sets an approved amount, pays 80% of it, and you pay 20%.

Before Medicare pays anything, you must meet your Part B deductible for the year. In 2024, that deductible is $240. Once you have paid $240 out of pocket toward Part B services, your coinsurance kicks in and Medicare begins paying its 80%.

The 20% you owe is called coinsurance. If Medicare approves $5,000 for your surgery, you would pay $1,000 (20%) after your deductible is met. If the surgeon or facility charges more than Medicare approves, you may owe that difference too — though many providers accept Medicare's approved amount as payment in full.

Hospital outpatient department versus surgical center

Where your surgery takes place matters for your costs. A hospital outpatient department is part of a hospital. An independent surgical center is a separate facility not owned by a hospital. Medicare covers both, but the facility charges differ.

Hospital outpatient departments typically charge more because hospitals have higher overhead. You will owe 20% coinsurance on the hospital's approved amount. Independent surgical centers usually have lower approved amounts, so your 20% coinsurance is smaller in dollar terms.

Ask your surgeon where the procedure is scheduled. If you have a choice, request a cost estimate from both locations. Your surgeon's office can contact Medicare or use online tools to find what Medicare approves at each facility for your specific procedure.

What you need to know before surgery

Contact your surgeon's office at least two weeks before the scheduled date and ask them to find out what Medicare approves for your procedure. They should be able to tell you the approved amount and estimate what your 20% coinsurance will be.

Confirm whether you have already met your Part B deductible for the year. If you have not, add $240 to your estimated coinsurance. If you are unsure, call Medicare at 1-800-MEDICARE and give them your Medicare number — they can tell you your deductible status.

Ask the surgeon's office whether they accept Medicare's approved amount as full payment or whether they charge above it. Most do accept it, but some do not. If they charge above Medicare's approved amount, ask how much the difference will be.

How Medigap and Medicare Advantage affect your costs

If you have a Medigap policy (supplemental insurance), it typically covers your 20% coinsurance and may cover your deductible. This means you could owe very little or nothing out of pocket for outpatient surgery. Check your Medigap policy documents or call your insurance company to confirm what it covers.

If you have a Medicare Advantage plan, your coverage works differently. Advantage plans set their own copays and coinsurance amounts, which may be higher or lower than Original Medicare's 20%. Call your Advantage plan before surgery and ask what you will owe for outpatient surgery at the specific facility where your procedure is scheduled.

Some Advantage plans require you to use in-network facilities. If your surgeon's facility is out of network, your costs could be much higher. Confirm in-network status before scheduling.

When Medicare does not cover outpatient surgery

Medicare Part B covers most medically necessary outpatient surgery. It does not cover cosmetic surgery unless it is reconstructive — for example, surgery to repair damage from an accident or illness. Cosmetic procedures like facelifts or eyelid lifts for appearance alone are not covered.

Medicare also does not cover some experimental procedures or those deemed not medically necessary. Your surgeon should know whether Medicare covers your specific procedure, but you can also ask Medicare directly by calling 1-800-MEDICARE or checking Medicare.gov.

If Medicare denies coverage, you will receive a notice called a Advance Beneficiary Notice (ABN) before surgery. This notice tells you that Medicare may not pay and estimates what you could owe. You can choose to proceed and pay out of pocket, or cancel the procedure.

Questions to ask your surgeon before outpatient surgery

Write down these questions and call your surgeon's office at least two weeks before your scheduled date:

  • What is the procedure code (CPT code) for my surgery?
  • What does Medicare approve for this procedure at your facility?
  • What will my 20% coinsurance be?
  • Have I met my Part B deductible this year?
  • Do you accept Medicare's approved amount as full payment?
  • If not, how much will I owe above Medicare's approved amount?
  • Will I receive an Advance Beneficiary Notice before surgery?
  • Can you send me a written estimate of my total out-of-pocket cost?

Frequently Asked Questions

Do I need Part B to have outpatient surgery covered?

Yes. Part B is what covers doctor services and outpatient procedures. If you have Original Medicare, Part B is automatic at age 65 unless you delayed it. If you have a Medicare Advantage plan, it includes Part B coverage. Without Part B, Medicare will not pay for outpatient surgery.

What happens if the surgeon charges more than Medicare approves?

If the provider is a Medicare-participating provider, they must accept Medicare's approved amount. If they are non-participating, they can charge up to 15% above the approved amount. Ask your surgeon's office whether they participate with Medicare before scheduling.

Will I owe anything if I have Medigap?

Most Medigap plans cover your 20% coinsurance and deductible, so you may owe nothing. However, coverage varies by plan. Check your policy documents or call your Medigap insurer to confirm what your plan covers for outpatient surgery.

Can I get an estimate before surgery?

Yes. Your surgeon's office can contact Medicare or use online lookup tools to find the approved amount for your procedure at their facility. Ask them to provide a written estimate of your coinsurance and any costs above Medicare's approved amount.

What if I cannot afford my out-of-pocket costs?

Talk to your surgeon's office about payment plans. Some facilities offer financial information or payment arrangements. You can also contact your local Area Agency on Aging to learn about programs that may help with medical costs.