Does Medicare Cover Surgery?
Key Takeaways
- Original Medicare or a Medicare Advantage plan helps to pay the costs of medically necessary surgeries.
- Medicare Part A covers inpatient surgeries.
- Medicare Part B covers outpatient operations.
- Medicare Advantage plans match Original Medicare coverage and can provide additional benefits.
Does Medicare Pay for Operations?
Surgery is stressful and potentially expensive, so it’s important to go in confident that you have the medical coverage you need.
Most U.S. adults who are 65 or older get their health insurance through either Original Medicare, which is administered by the federal government, or a Medicare Advantage plan from a private insurer.
Medicare helps with the costs of medically necessary surgeries, but that doesn’t include all surgeries, and you may be responsible for some expenses. Here’s what you need to know about Medicare surgery coverage.
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What Medical Procedures Are Covered by Medicare?
There are two parts to Original Medicare. Medicare Part A, which is hospital insurance, applies to inpatient surgery, and Medicare Part B, which is medical insurance, covers outpatient operations. Part B also helps to pay for doctor’s services you may receive while you’re in the hospital.
Original Medicare covers medically necessary surgeries. That can include emergency surgeries with the potential to save your life, but also operations you can schedule ahead of time, such as a joint replacement surgery or tumor removal. Medicare Advantage plans are required to at least match the coverage provided by Original Medicare.
Does Medicare Require Preauthorization for Operations?
Preauthorization is a process where insurance carriers confirm that certain care is medically necessary. It requires doctors to submit documentation that explains why they are ordering a procedure.
For most surgeries, Original Medicare does not call for preauthorization. Some outpatient surgeries may require preauthorization to confirm they’re medically necessary. Medicare Advantage plans may ask for preauthorization before scheduling surgeries.
Does Medicare Cover Oral Surgery?
Medicare Part B covers some types of oral surgery, such as jaw surgery or facial surgery. Surgeries related to bones, blood vessels, or the tongue are generally covered.
But if the surgery only involves the gums or teeth, you won’t get Part B coverage. Oral surgery on teeth and gums is classified as dental surgery, and it’s not covered under Original Medicare. For oral health coverage, you’ll need either a standalone dental insurance plan or a Medicare Advantage plan that includes additional dental benefits.
Does Medicare Cover Inpatient Surgery?
Medicare Part A provides hospital insurance, including inpatient surgery. Part A covers both emergency and non-emergency surgeries.
What About Part A Deductibles and Coinsurance?
Before your Part A coverage kicks in, you’ll need to meet the deductible for your stay. If you’re in the hospital between 1 to 60 days, you pay $0 coinsurance after hitting the deductible. For stays of more 60 days, you’ll start paying a daily coinsurance amount.
Does Medicare Part A Cover Outpatient Surgery?
Medicare Part A does not cover outpatient surgery. Part A only covers inpatient operations. Medicare costs and coverage are different for inpatient versus outpatient care. So, before your operation, make sure you know what’s covered.
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Does Medicare Cover Outpatient Surgery?
Medicare Part B covers medical expenses, including medically necessary outpatient surgery. Typically, outpatient surgeries are short operations, and you won’t need to stay overnight in the hospital. Some common outpatient surgeries include biopsies, cataract surgery, or a gastric bypass. Even if you do end up staying for a night, Part B still covers outpatient procedure.
Part B Deductibles
Your annual Part B deductible applies to outpatient surgeries. You must reach your deductible before Part B covers a portion of the cost of your operation. After you pay your yearly deductible, coinsurance or copayments will apply.
What Percentage Does Medicare Pay For Surgery?
After you meet the deductible for your stay, Medicare Part A covers the costs of an inpatient surgical procedure, a hospital room, meals, and general nursing for the first 60 days.
Medicare Part B generally pays for 80% of covered services such as an outpatient surgery or a doctor’s visit after you reach your deductible for the year, Part B covers 80% of all approved costs. This leaves you to pay the remaining 20% out-of-pocket.
Keep in mind that there’s no limit on out-of-pocket Part B spending. You will continue paying a 20% coinsurance for your operation, and throughout the year. That means medical expenses can add up, even if you have Part B coverage.
What Surgeries Are Not Covered by Medicare?
There are some operations that aren’t included in Medicare surgery coverage. If you choose to have elective surgery, it’s not considered medically necessary because it won’t save your life or improve your health. For example, Medicare does not cover cosmetic surgeries, mole removal, or Botox.
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Do Medicare Advantage Plans Cover Operations?
Medicare Advantage plans offer the same hospital and medical coverage as Original Medicare. But there are some big differences:
- Medicare Advantage plans have an annual out-of-pocket limit on healthcare spending. This can cut back on your medical costs and make the care you need more affordable in the long run.
- To get the most out of your benefits, Medicare Advantage plans may require you to visit doctors, healthcare facilities, and pharmacies that are in your provider network.
- While the vast majority of hospitals accept Original Medicare, you will need to check that a specific facility takes your Medicare Advantage plan.
- Medicare Part D prescription drug coverage to help with the costs of any medications you need before or after your surgery.
- Lower deductibles.
- Additional coverage for hospital care and rehabilitation services.
- Homecare services and more support while you recover from surgery.
- Home-delivered meals so you don’t have to think about cooking while you get back on your feet.
Sources
- Prior Authorization for Certain Hospital Outpatient Department (OPD) Services. CMS.gov.
- Medicare Dental Coverage. CMS.gov.
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