Ambulatory surgical centers (ASCs) offer outpatient surgical care, allowing patients to return home the same day. They provide a cost-effective alternative to hospital-based procedures and are increasingly popular for their convenience and affordability. But what role do Medicaid and Medicare play in covering costs associated with ASCs?
What are ambulatory surgical centers?
ASCs are specialized healthcare facilities offering diagnostic, preventive, and surgical services outside traditional hospital settings. They cater to low-risk, same-day surgeries such as colonoscopies, cataract surgery, and orthopedic procedures. Thanks to technological advancements, many procedures once requiring hospital stays are now safely performed in ASCs, ensuring faster recovery and lower costs.
Medicare coverage for ambulatory surgical centers
What is covered?
Medicare Part B covers medically necessary procedures performed in ASCs. This includes a wide range of surgical procedures, such as cataract surgery, colonoscopies, and other approved outpatient surgeries. Medicare pays for facility costs at ASCs for covered procedures, but not for cosmetic or experimental surgeries. Preventive services, like screening colonoscopies, are often fully covered, although additional procedures (e.g., polyp removal during a colonoscopy) may incur out-of-pocket costs.
Cost breakdown
Once you meet the annual Part B deductible, Medicare covers 80% of the approved amount for the procedure, leaving you responsible for the remaining 20%. Facility fees and any services not covered by Medicare must be paid out-of-pocket. It’s necessary to verify whether your procedure is on Medicare’s list of approved services and whether your provider accepts Medicare assignment for fair pricing.
Facility fees for non-covered procedures
Medicare does not cover non-essential or cosmetic surgeries performed at ASCs. Patients are responsible for all associated costs in such cases. For cost transparency, Medicare offers a Procedure Price Lookup tool, which provides price estimates for outpatient services at ASCs and hospital outpatient departments.
Eligibility criteria
Medicare beneficiaries are eligible for ASC services if:
- The procedure is deemed medically necessary.
- The ASC is Medicare-certified.
- The patient’s condition is stable enough for outpatient surgery
Medicaid coverage
Medicaid, a joint federal and state program, also provides coverage for ASC services, but eligibility and benefits differ widely by state. Generally, Medicaid covers medically necessary procedures, often focusing on low-income families, children, pregnant women, and individuals with disabilities. Unlike Medicare, Medicaid beneficiaries may have lower or no copays for services at ASCs, depending on state guidelines.
It’s advisable to contact your state’s Medicaid office to determine coverage specifics for ambulatory surgery and associated costs.
Prior authorization
Some states require prior authorization for surgeries performed at ASCs to ensure medical necessity and cost-effectiveness. Beneficiaries are encouraged to consult their Medicaid plan or state Medicaid office to confirm coverage.
Benefits of ambulatory surgical centers
- Cost savings
ASCs offer significant cost advantages over hospital outpatient departments, often charging lower facility fees for similar procedures. Medicare has documented substantial savings for beneficiaries utilizing ASCs.
- Convenience and efficiency
ASCs prioritize patient-centered care with streamlined services, shorter wait times, and a less intimidating clinical environment compared to hospitals. These factors enhance the overall patient experience.
