For many people, having a surgical procedure for any number of reasons is a common occurrence. But for older Americans, it’s a valid question to ask if Medicare covers surgery. Then, if so, what exactly does the program deem worthy of coverage?

Besides Original Medicare, there are also Medicare Advantage and Medicare Supplemental plans that can increase your benefits for surgeries. Continue reading to comprehensively find out about your options.

Is Surgery Covered By Medicare?

Medicare covers many different types of surgeries, both inpatient and outpatient. However, the specifics of coverage vary depending on the type of Medicare plan you have.

In general, Medicare will cover surgeries deemed medically necessary. This means that surgery is necessary to treat an illness or injury, and there is no other treatment option available.

Discuss all of your options with your doctor if you’re considering surgery. They can help you decide what options are available and if surgery is a necessity.

Medicare Advantage Coverage for Surgeries

On a Medicare Advantage plan, your coverage for surgery will likely be different than if you have Original Medicare or a Medicare Supplement plan. Medicare Advantage plans pay instead of Original Medicare.

They must offer coverage at least as good as Original Medicare and usually include benefits Medicare doesn’t. It’s essential to read the details of coverage for your specific plan.

Medicare Supplemental Plans’ Coverage for Surgeries

Medicare Supplement plans are private insurance plans that work with Original Medicare. They help pay for some of the costs not covered by Original Medicare. Like Medicare Advantage plans, each Medicare Supplement plan is different.

Outpatient Surgery

In general, outpatient surgeries will be covered by Original Medicare, Medicare Advantage, and Medicare Supplement plans. Outpatient means that the surgery will be performed in a hospital, but you won’t have to stay overnight in most cases.

There are exceptions to this rule, so be sure to read the details of your specific plan.

Medicare and Outpatient Surgery

Suppose you are on Original Medicare and have surgery. You’ll pay the Part B deductible. Once you’ve met the Part B deductible, you will be responsible for 20% of the bill and any excess charges.

Medicare Advantage and Outpatient Surgery

Most Medicare Advantage plans have set copays for outpatient surgery. The copay can vary depending on where the procedure is performed. An example would a surgery is being performed at the hospital could have a different cost than the same surgery performed at a surgery center.

Medicare Supplement and Outpatient Surgery

Medicare supplements pick up your portion of the costs left to you by Original Medicare. This means depending on the plan letter, you should have little or nothing to pay out of pocket for covered surgeries.

Inpatient Surgery

Medicare covers inpatient surgeries, which means you will have to stay in the hospital overnight. Most inpatient surgeries are emergency surgeries, but most surgeries take place in an outpatient setting.

Medicare will cover inpatient surgery. Once you meet your Medicare Part A deductible, Medicare should cover most inpatient surgical costs. Additional coinsurance may be a requirement depending on the situation, the length of your stay, etc.

Medicare Advantage and Inpatient Surgery

Medicare Advantage plans typically have a per-day hospital copay. They also have a separate copay for inpatient surgery.

Medicare Supplement and Inpatient Surgery

Most Medicare Supplement plan letters will cover all impatient surgery costs. Check your plan letter benefits to verify how much coverage you have.

FAQs

Does Part A cover outpatient surgery?

No, Part A only covers inpatient surgery. Part B covers outpatient surgery.

Does Medicare cover surgery if it’s not an emergency?

It depends on the situation and your coverage. Original Medicare, Medicare Advantage, and Medicare Supplement options have different outpatient surgery coverage. Review the details of your specific plan.

Does Medicare require prior authorization for surgery?

It depends on the surgery and your coverage. Medicare Advantage plans could require prior authorization for some surgeries, while Original Medicare usually does not. Review the details of your specific plan.

Can I use my Medicare Advantage plan if I am hospitalized for surgery?

Yes, most plans have a per-day copay you pay when admitted to the hospital.

Does Medicare cover heart surgery?

Yes, Medicare covers heart surgery.

Does Medicare cover hip replacement surgery?

Yes, Medicare covers hip replacement surgery.

Is there a limit to how much Medicare will pay for surgery?

There is no limit to how much Medicare will pay for surgery. You could be responsible for additional costs depending on the situation.

Does Medicare cover joint replacement surgery?

Yes, Medicare covers joint replacement surgery.

Is outpatient surgery covered under Medicare Advantage?

Yes, Medicare Advantage plans often cover outpatient surgery. Check the details of your specific plan to be sure.

What is the difference between inpatient and outpatient surgery?

Inpatient surgery means you will have to stay in the hospital overnight. Outpatient surgery means you will not have to stay overnight. An outpatient setting is where the majority of surgeries take place.

Does Medicare pay for elective surgery?

Medicare will only pay for surgery if it’s medically necessary. While it’s possible to have an elective surgery that is also necessary, it’s rarer than normal surgery.

How Can I Get Help Paying for Surgery Costs?

Medicare covers a lot, but not everything, when you have a necessary surgical procedure. If you have no interest in paying the remaining 20%, it might be a great idea for you to explore getting a Medicare Supplemental plan. For a monthly premium, it’s possible to pay very little — or nothing — out of pocket should surgery be on the horizon.

We have licensed insurance agents who are experts in the Medicare field and will take their time to answer any questions or compare plans with you. Speaking with our agents is complimentary for you, so there’s no reason not to!

Give our agents a call today, or fill out our online request form so you can be hooked up with the best rates in your area.

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by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.