Does Medicare Cover Surgery?
Medicare covers medically necessary surgeries. It generally does not cover cosmetic surgery. Medicare Part A covers inpatient procedures, while Part B covers outpatient procedures. Your out-of-pocket costs will depend on several factors, including where the surgery takes place.
Understanding Medicare Surgery Coverage
Medicare surgery coverage can be confusing and challenging to understand.
It’s difficult to determine exactly how much you’ll owe out-of-pocket because so many factors influence surgery cost.
Your Medicare coverage and out-of-pocket costs are different for inpatient and outpatient surgeries.
It is important to understand that you can receive care in a hospital and still be considered an outpatient.
- Whether the surgery is considered inpatient or outpatient.
- Where the surgery takes place. (For example, it may be cheaper to undergo outpatient surgery at an ambulatory surgical center than in a hospital outpatient department.)
- What part of the country you live in.
- How many doctors perform your surgery.
- If you have any supplement insurance, such as Medicaid or a Medigap policy.
- If you’ve already met your Part A or Part B deductibles.
- If treatment includes more than one procedure or if complications arise after surgery.
Surgery is one of several treatments covered under Medicare. A procedure must be considered medically necessary to qualify for coverage. This means the surgery diagnoses or treats an illness, injury, condition, disease or its symptoms.
To keep your costs low, make sure the doctor performing your surgery accepts Medicare assignment. This means the doctor agrees to accept the Medicare-approved cost for the procedure and won’t bill you anything besides a copayment or coinsurance fee.
Medicare Advantage Coverage for Surgery
Medicare Advantage plans are administered by private companies that contract with the federal government. Plans must include the same basic care as Original Medicare but often bundle other benefits — such as vision and dental — into a single plan.
Medicare Advantage plans may require you to use hospitals and doctors within the plan’s network for your surgery. Prior authorization is usually required.
Medicare Advantage plans may also have different deductibles, coinsurance and copayments for surgery than Original Medicare.
For example, the AARP Medicare Advantage Choice (PPO) plan features a $295 per day coinsurance payment for inpatient hospital care (days one through six). This is in addition to the standard Medicare Part A deductible of $1,556 in 2022.
After day six, there are no coinsurance payments with this plan.
A different Medicare Advantage plan — UnitedHealthcare Dual Complete® RP (Regional PPO D-SNP) — features $0 copayments for each Medicare-covered hospital stay for unlimited days, as long as the hospital is within the plan’s network.
In contrast, Original Medicare’s inpatient hospital policy features a $0 coinsurance payment for the first 60 days of inpatient care after you meet the Part A deductible.
Contact your specific Medicare Advantage plan’s customer service department or consult your annual evidence of coverage manual for details about inpatient and outpatient surgery coverage.
Does Medicare Cover Outpatient Surgery?
Medicare Part B covers outpatient surgery. Typically, you pay 20 percent of the Medicare-approved amount for your surgery, plus 20 percent of the cost for your doctor’s services.
The Part B deductible applies ($233 in 2022), and you pay all costs for items or services Medicare doesn’t cover.
You usually also pay the hospital a facility fee copayment and 20 percent for each service you receive in a hospital outpatient setting.
However, there’s an exception for costly surgical procedures. For these comprehensive procedures, you pay 20 percent of the entire cost, including the surgery plus any drugs, laboratory tests or other services you may receive.
If you are billed for separate services, your copayment for each service can’t exceed the Part A deductible ($1,556 in 2022).
Outpatient surgery refers to a procedure a doctor performs without formally admitting you into the hospital.
It usually takes place in a doctor’s office, an ambulatory surgical center or a hospital.
Outpatient surgery is on the rise in the United States. According to 2020 data from Sg2 — a health care consulting firm headquartered in Skokie, Illinois — about 83 percent of surgical procedures are now performed in an outpatient setting.
As outpatient surgery grows more popular, so too have ambulatory surgical centers — non-hospital facilities where certain procedures are performed for patients who aren’t expected to need more than 24 hours of care.
According to the National Law Review, studies show that ambulatory surgical centers “offer consistently lower costs than hospitals, providing strong incentives for patients to shift their site of care.”
The U.S. Centers for Medicare & Medicaid Services (CMS) has also increased the number of procedures that can be performed at ambulatory surgery centers. A recent CMS outpatient payment rule added 267 additional procedures eligible for reimbursement starting in 2021.
Where your outpatient surgery takes place matters. This can significantly impact your out-of-pocket costs.
For example, an outpatient laparoscopic hysterectomy is estimated to cost Medicare beneficiaries $943 out-of-pocket at an ambulatory surgical center, while the same procedure can cost $1,669 at a hospital outpatient department, according to Medicare’s Procedure Price Lookup tool.
However, ambulatory surgical centers may not always be cheaper. A total knee replacement, for example, is estimated to cost Medicare beneficiaries $2,015 at an ambulatory surgery center verses $1,748 at a hospital outpatient department.
The type of surgery performed also impacts your cost. For example, there are several types of mastectomies, or the surgical procedures to remove breast tissue in breast cancer patients.
An outpatient partial mastectomy is estimated to cost between $389 and $761 out of pocket, according to Medicare’s procedure cost tool. In contrast, a modified radical mastectomy — a more complex version that involves removing the lymph nodes and some chest muscles — averages between $694 and $1,350.
It’s important to note that all estimates from Medicare’s Procedure Price Lookup are based on Original Medicare coverage without supplement insurance, such as Medicaid or a Medigap policy.
These estimates also don’t apply to beneficiaries with Medicare Advantage. If you have a Medicare Advantage plan, talk to your plan provider about outpatient surgery costs.
Does Medicare Cover Inpatient Surgery?
Medicare Part A covers expenses related to inpatient hospital stays and surgeries.
Typically, you’ll receive an all-inclusive package of services when you’re admitted to the hospital and pay the Part A deductible of $1,556 for a stay of up to 60 days.
You’ll also owe 20 percent of the doctor’s charges.
- $1,556 deductible for each benefit period.
- Days 1–60: $0 coinsurance for each benefit period.
- Days 61–90: $389 coinsurance per day of each benefit period.
- Days 91 and beyond: $778 coinsurance per each lifetime reserve day (up to 60 days over your lifetime).
- Beyond lifetime reserve days: All costs.
It’s important to note that you may owe the Part A deductible multiple times in a single year.
Medicare Part A deductibles work differently than most health insurance deductibles. Usually, you have one deductible for the entire year, and you pay that amount out-of-pocket before your insurance kicks in. Then your deductible resets the following year.
Medicare Part A uses what’s known as benefit periods. A benefit period begins the day you go into the hospital and ends when you’ve been out of the hospital for 60 days in a row.
If you’re readmitted to the hospital 60 days or more after you were discharged, then a new benefit period begins, and you’ll owe the $1,556 Part A deductible again.
How to Estimate Your Surgery Cost with Medicare
Talking to your doctor and health care team about costs prior to surgery is a good way to avoid surprise billing.
Call the hospital or facility and ask them to tell you about the copayment for the specific surgery or procedure your doctor will perform. Ask if they charge a facility fee.
Make sure to ask your doctor, surgeon or other health care provider what kind of care or services you may need after your procedure — along with a cost estimate.
- Is this procedure covered by Medicare?
- Which hospitals or ambulatory surgical centers do you work with when you perform this type of procedure?
- Which facility is the best place for me to get this surgery?
- Does the facility you recommend participate in Medicare?
- Do I need permission (such as prior authorization or a referral) before my operation?
While it’s always a good idea to get an estimate in advance for non-emergency surgery, it’s important to understand that estimates can be wrong. For example, if you need other unexpected services, your costs may be higher.
According to Kaiser Health News, hospital estimates are often inaccurate and there is no legal obligation that they be correct.
Even if your bill ends up higher than expected, having an estimate is useful. It can help you make the argument with your provider and Medicare that you shouldn’t be charged more than you expected.
Surgical Procedures Not Covered Under Medicare
A surgery must be considered medically necessary to qualify for Medicare coverage. Investigational procedures aren’t covered.
Medicare generally won’t cover cosmetic surgery either, but there are a few exceptions.
Medicare may cover cosmetic surgery if it repairs an accidental injury or improves the function of a malformed body part.
- Surgery to treat severe burns
- Surgery to repair the face after a serious car accident
- Therapeutic surgery that coincidentally serves a cosmetic purpose
For example, rhinoplasty to correct a malformed nasal passage and chronic breathing issues can simultaneously improve the appearance of your nose. Or a procedure that removes excessive eye skin to improve vision may also make your eyelids appear less droopy.
It’s important to note that Medicare covers breast reconstruction procedures following a mastectomy or lumpectomy, as it doesn’t consider these procedures to be cosmetic surgeries.
13 Cited Research Articles
- Yood, K., Gertler, M. R. and Stobaugh, A. R. (2021, May 20). Biden’s American Rescue Plan Follows Trend Toward Outpatient Setting, Increase in ASC Investment. Retrieved from https://www.natlawreview.com/article/biden-s-american-rescue-plan-follows-trend-toward-outpatient-setting-increase-asc
- King, R. (2021, April 5). COVID-19 Accelerates Trend of Hospitals Acquiring Ambulatory Surgery Centers. Retrieved from https://www.fiercehealthcare.com/hospitals/covid-19-accelerates-trend-hospitals-acquiring-ambulatory-surgery-centers
- Jaffe, S. (2021, March 23). Under New Cost-Cutting Medicare Rule, Same Surgery, Same Place, Different Bill. Retrieved from https://khn.org/news/article/trump-medicare-inpatient-only-rule-risky-surgery-procedures-patient-cost-burden-catch-22/
- U.S. Centers for Medicare & Medicaid Services. (2020, December). Items & Services Not Covered Under Medicare. Retrieved from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/items-and-services-not-covered-under-medicare-booklet-icn906765.pdf
- OR Manager. (2020, November 17). Shifts In Case Mix Bode Well for Future of Outpatient Surgery. Retrieved from https://www.ormanager.com/shifts-case-mix-bode-well-future-outpatient-surgery/
- BreastCancer.org. (2020, February 26). Paying for Reconstruction Procedures. Retrieved from https://www.breastcancer.org/treatment/surgery/reconstruction/paying-for
- UnitedHealthcare. (2020). Evidence of Coverage: UnitedHealthcare Dual Complete® RP (Regional PPO D-SNP). Retrieved from https://www.uhccommunityplan.com/assets/plandocuments/2020/eoc/en/2020-VA-EOC-R1548-001-000-EN.pdf
- Bluth, R. (2019, August 30). They Got Estimates Before Surgery — And A Bill After That Was 50% More. Retrieved from https://khn.org/news/they-got-estimates-before-surgery-and-a-bill-after-that-was-50-more/
- U.S. Centers for Medicare & Medicaid Services. (2019, July). Learning What Medicare Covers & How Much You Pay. Retrieved from https://www.medicare.gov/Pubs/pdf/11472-Learn-What-Medicare-Covers.pdf
- Freeman, W. J., Weiss, A. J. and Heslin, K. C. (2018, December). Overview of U.S. Hospital Stays in 2016: Variation by Geographic Region. Retrieved from https://www.hcup-us.ahrq.gov/reports/statbriefs/sb246-Geographic-Variation-Hospital-Stays.jsp
- Medicare.gov. (n.d.). Inpatient Hospital Care. Retrieved from https://www.medicare.gov/coverage/inpatient-hospital-care
- Medicare.gov. (n.d.). Surgery. Retrieved from https://www.medicare.gov/coverage/surgery
- Medicare.gov. (n.d.). Which Facility Is Best For My Outpatient Procedure? Retrieved from https://www.medicare.gov/what-medicare-covers/outpatient-facility-checklist