Medicare covers a wide variety of medical services. However, it can be unclear at times as to what specific services will be covered, including surgeries. So, does Medicare cover surgery?
Medical Necessity
Yes, Medicare covers surgeries when medically necessary. If the procedure is not considered to be medically necessary, Medicare will likely not provide coverage. A service is usually considered medically necessary when it is used to treat, diagnose, or monitor a health condition.
Your exact costs for a procedure will vary depending on a range of factors, including the type of surgery, what Medicare plans you have, and more.
Medicare Part B helps cover the cost of your surgery in both an outpatient and inpatient setting. If you are officially admitted to a hospital, Medicare Part A and will help cover additional costs, including room and board and meals.
If you are new to Medicare, these different terms may be confusing. It’s good to have a basic understanding of Medicare and how it works first: boomerbenefits.com/understanding-medicare/
Outpatient Surgery
Medicare Part B will help cover the costs of a procedure if your surgery is done in an outpatient setting. You’re considered an outpatient if you receive surgery or other medical services and have not been admitted to the hospital. Even if you have surgery in a hospital and spend the night, you still may be considered an outpatient.
Part B pays for 80% of Medicare-approved costs, which means you are responsible for the remaining 20%. However, a Medicare Supplement plan (Medigap plan) will help cover all or some of the 20%, depending on your plan.
Keep in mind you will need to meet the annual Part B deductible first before your Medigap plan can step in. The Part B deductible is $233 in 2022.
Inpatient Surgery
Part B also helps cover your surgery costs as an inpatient, which is anytime you are formally admitted to a hospital due to a doctor’s order. However, staying as an inpatient in a hospital comes with additional costs, and that’s where Part A comes in. Part A helps cover room and board, meals, and other hospitalization costs associated with your stay.
Part A also functions a little differently than Part B when it comes to cost-sharing. With Part A, you have a deductible for each benefit period. A benefit period begins the day you are admitted as an inpatient and ends after you haven’t received inpatient hospital services for 60 consecutive days. The Part A deductible for each benefit period $1,556 in 2022.
If you meet this deductible and are still receiving care as an inpatient, you will begin paying a coinsurance. If you’re in the hospital for 61 to 90 days in one benefit period, you will pay $389 each day. Once you’ve been in the hospital for more than 90 days, you pay $778 for each lifetime reserve day.
Advantage Plans
When you sign up for an Advantage plan, you agree to receive your Part A and Part B benefits through a private carrier instead. However, each Advantage plan must provide the same services Part A and Part B do.
This means your Advantage plan should also cover any medically necessary surgeries. The costs for surgery with an Advantage plan depend on the plan and the type of surgery. Advantage plans also operate within network areas, so it’s good to stay in-network if you can to avoid extra costs.
Surgery Not Covered by Medicare
Although Medicare can cover medically necessary surgeries, it will not cover cosmetic surgery in most cases. Medicare typically does not consider these types of surgeries to be medically necessary.
There are certain situations where Medicare may provide coverage for cosmetic reasons. For example, if the surgery addresses an accidental injury or improves the state of a malformed body part, Medicare may provide coverage.
Final Thoughts
Medicare can cover many medically necessary surgeries. To prepare for any potential costs, consider whether you will be an inpatient or an outpatient if possible. It may be beneficial to speak with your healthcare provider beforehand to discuss what to expect in terms of cost.