Key takeaways
Medicare covers medically necessary surgery, both inpatient and outpatient surgery when recommended by a doctor to diagnose or treat a medical condition.
This is how original Medicare pays for surgery: Part A covers inpatient surgeries in hospitals, while Medicare Part B will cover outpatient surgeries in a hospital or outpatient setting like clinics and ambulatory centers. For outpatient surgery, the Part B deductible applies.
Medicare considers the relatedness of multiple procedures and health care provider’s services. It bundles payments for related surgeries and provides separate payments for unrelated doctor services. For example, required medical tests done pre-surgery that are related to your inpatient surgery will be bundled under Part A
Medicare Advantage plans typically cover medically necessary surgery too but the coverage details can vary depending on the specific Medicare Advantage plan you have, and change yearly.
Medicare supplement plans help cover the deductibles, copays and coinsurance of Original Medicare. .
Does Medicare Cover Inpatient Surgery?
Medicare covers medically necessary inpatient surgery. Medicare Part A, which is the hospital insurance portion of Original Medicare, covers inpatient hospital stays, including surgical procedures that require you to be admitted to the hospital. Part A also covers other hospital services such as room and board, nursing care, and necessary medications during your hospital stay.
Cost of Inpatient Surgery with Traditional Medicare
Medicare Part A has a deductible that you or your supplement must pay before Medicare coverage begins for inpatient hospital stays. This deductible is generally for each benefit period, which starts when you’re admitted to a hospital and ends when you’ve been out of the hospital for 60 consecutive days. After you’ve met the deductible, Medicare generally covers the costs of inpatient care for up to 60 days in a benefit period. If your hospital stay extends beyond 60 days, you or your supplement will incur daily coinsurance costs.
With most Medicare supplements you can spend up to a year in the hospital and not pay a dime. The Medicare supplement can turn costly surgical procedures into fully paid for inpatient care.
Every Advantage Plan has its own inpatient deductible. Check your Summary of Benefits for details.
Medicare can also cover ambulance services related to surgery or emergency care. Being transported from your home to the hospital for surgery or for post-surgery care. Coverage depends on whether you’re under Medicare Part A or Part B, and your doctor’s certification is required.
Skilled nursing facilities care
If you need post-hospitalization care in a skilled nursing facility, Medicare can also cover a portion of those home health services, provided you meet certain criteria. This coverage is related to your initial hospital stay and the need for skilled care or rehabilitation. Please see our other posts on how Medicare pays for this.
Do Medicare Advantage Plans Pay for Inpatient Surgery?
With a Medicare Advantage plan, your hospital inpatient surgery coverage will be provided through the private insurance company that administers your plan. There are over 4,000 different Medicare Advantage Plans in the U.S., each with different benefits and costs. Check your Summary of Benefits for details on your plan coverage.
Does Medicare Cover Outpatient Surgery?
Medicare covers outpatient surgery through Medicare Part B.
Medicare covers outpatient surgery that is considered medically necessary. This means that the surgery must be recommended by a doctor to diagnose or treat a medical condition. Cosmetic surgeries, for example, are not covered unless it’s necessary for a medical reason.
Original Medicare (Part A and Part B) covers a wide range of outpatient medical services, including surgical procedures performed in an outpatient setting, such as a hospital outpatient department, or an ambulatory surgical center.
The cost of outpatient surgeries with original Medicare
Medicare Part B generally covers 80% of the Medicare-approved amount for outpatient surgery after you meet your annual Part B deductible. You, or your supplement, will also be responsible for the 20% coinsurance for the Medicare-approved amount for doctor’s services in a hospital outpatient setting.
Medicare prescription drug coverage
When you are an inpatient, Medicare Part A covers all medications administered to you while you are an inpatient. If your surgery is under Part B as an outpatient, medications administered by a medical professional are typically covered under Part B.
Your Part D prescription drug coverage is used for self administered prescriptions you pick up from a pharmacy.
Will Medicare Advantage plans cover outpatient surgery?
Medicare Advantage plans are intended to cover at least the same benefit categories as Original Medicare, however, they often have their own rules and coverage specifics. If you have a Medicare Advantage plan, your out-of-pocket costs for outpatient surgery might differ and could include copayments or coinsurance, which can vary based on the plan.
Does Medicare Part B Cover Surgery?
Medicare will cover outpatient surgery through Medicare Part B. Part B typically covers 80% of the Medicare-approved amount for covered (medically necessary) outpatient surgery. You or your supplement will be responsible for the remaining 20% as coinsurance.
If you have other services or tests related to the surgery, such as lab tests or
imaging, these services may also be covered under Part B, subject to your Part B deductible and coinsurance.
If your doctor determines that you need durable medical equipment or medical supplies to aid in your recovery after surgery, Medicare Part B may also pay for some of the costs.
When we talk about Medicare Part A or B in this context, there’s a concept called “global surgical package,” which covers not only the surgery itself but also certain related services provided during a specific time frame before and after the surgery. This package covers services such as pre-operative visits, post-operative follow-up care, and necessary supplies.
Does Medicare Pay 100% of Surgery?
Original Medicare does not pay 100% of the costs for surgery. Both Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) have cost-sharing requirements that you are responsible for with your doctor or other health care provider.
However, when you combine Medicare with a supplement, they can cover outpatient surgery at 100% and inpatient surgery at 100% as well.
What Surgical Procedures are Covered by Medicare?
Medicare covers a wide range of surgical procedures that are medically necessary for the diagnosis or treatment of a medical condition. Medicare-covered services can vary based on factors such as the type of Medicare coverage you have (Original Medicare vs. Medicare Advantage) and the medical necessity of the procedure.
The surgical services covered by Medicare may include:
Major Surgeries
Medicare typically covers major surgical procedures that require hospitalization and are performed by licensed medical professionals. This can include procedures such as heart surgery, joint replacement surgery, and abdominal surgeries.
Minor Surgeries
Medicare also covers many minor surgical procedures that are performed in outpatient settings, such as ambulatory surgical centers or doctors’ offices. Examples of minor surgeries include cataract surgery, skin lesion removal, and hernia repair.
Endoscopic Procedures
Endoscopic procedures, which involve inserting a flexible tube with a camera and light into the body, are often covered by Medicare. This includes procedures like colonoscopy, upper endoscopy, and bronchoscopy.
Biopsies and Tissue Removal
Medicare covers procedures that involve the removal of tissue samples for diagnostic purposes. This includes biopsies of various body parts such as the skin, breast, prostate, and more.
Cardiovascular Procedures
Medicare covers a range of cardiovascular procedures, including angioplasty, stent placement, and pacemaker implantation, when they are medically necessary.
Orthopedic Procedures
Medicare covers orthopedic surgeries like hip and knee replacements when they are deemed medically necessary for the treatment of joint conditions.
Gastrointestinal Surgeries
Procedures such as gallbladder removal (cholecystectomy), appendectomy, and gastric bypass surgery might be covered when medically necessary.
Urological Procedures
Surgeries for conditions like kidney stones, urinary tract obstruction, and prostate issues may be covered by Medicare.
Neurological Procedures
Procedures such as spinal surgeries and certain brain surgeries may be covered when medically necessary.
What Surgery Does Medicare Not Cover?
Medicare does not cover certain surgical procedures that are considered
elective or cosmetic in nature, as well as some experimental or investigational procedures.
For example, Medicare typically doesn’t cover:
Cosmetic Surgery
Procedures performed solely for cosmetic reasons and not deemed medically necessary are generally not covered by Medicare. This includes surgeries such as facelifts, rhinoplasty (nose jobs), and breast augmentation for cosmetic purposes.
Dental Procedures
Dental surgery, including routine dental care and oral surgery related to dental problems, is typically not covered by Medicare. This includes procedures like tooth extractions, dental implants, and dentures.
Vision Correction Surgery
Surgeries for vision correction, such as LASIK eye surgery, are generally not covered by Medicare, as they are often considered elective.
Hearing Aids and Cochlear Implants
Medicare does not cover the cost of hearing aids or cochlear implants, which are devices used to address hearing loss.
Weight Loss Surgery
Medicare may cover weight loss surgery (bariatric surgery) if it’s deemed medically necessary to treat certain obesity-related conditions. However, surgeries performed primarily for weight loss purposes are often not covered.
Certain Experimental Procedures
Medicare typically does not cover experimental or investigational procedures that have not been established as effective treatments through clinical trials or medical research.
Routine Foot Care
Routine foot care, including cosmetic foot surgery and general foot care for non-medical reasons, is generally not covered. However, certain foot conditions related to medical issues like diabetes might be covered.
Elective Sterilization
Sterilization procedures, such as vasectomy or tubal ligation, are not covered by Medicare as they’re considered elective surgery.
What If Medicare Denies My Surgery?
If Medicare denies coverage for surgery, it means that they have determined that the procedure does not meet their criteria for medical necessity or that it falls outside the scope of covered services.
In this case, you will receive a notice from Medicare explaining the reason for the denial. This notice should include information about how to appeal the decision. Your healthcare provider can provide additional information and might be able to help address the denial.
If you believe the denial was made in error or if you have additional information that supports the medical necessity of the surgery, you have the right to appeal the decision.
How Does Medicare Pay for Multiple Surgical Procedures?
Medicare pays for multiple surgical procedures based on factors like their
relatedness and the setting in which they occur.
When multiple surgeries are performed during one operation, Medicare bundles payment, providing a single payment for the primary procedure and reduced payment for additional ones to avoid overcompensation. If surgeries are related and medically necessary for one condition, they’re often covered together.
However, unrelated surgeries addressing distinct medical issues might receive separate payments, with specific billing modifiers indicating the relationship between procedures.
The setting matters too; different rules apply for inpatient and outpatient procedures.
And remember that Medicare supplement plans (Medigap) can always help you cover the gaps in Original Medicare when it comes to surgery costs and other medical procedures…
We understand how the topic of surgery can make some Medicare beneficiaries feel uneasy, especially, in terms of healthcare coverage. We’re here for all of your questions and concerns. Call us and let us make Medicare simple, and choosing the right plan a breeze!
Matthew Claassen
Matthew Claassen, CMT and CEO of Medigap Seminars Insurance Agency. Medigap Seminars is an award winning premier national Medicare Insurance Brokerage, ranked among the top in the U.S.A. Matthew is considered a leading national expert on Medicare and Social Security. Mr. Claassen is a distinguished member of the Forbes Business council, an invitation only organization of business leaders and entrepreneurs. He and his team have received awards from many of the countries largest insurance companies including Mutual of Omaha, Aetna, Humana, Cigna, United American, United Healthcare and others. His videos have become the most popular Medicare educational videos on YouTube with millions of views. As a financial analyst Matthew lead a team of researchers to win the 2009 Best Equity Research & Strategy Award from The Technical analysis magazine.
