Does Medicare Cover Surgery?

Medicare surgery coverage can be confusing to navigate and challenging to understand.

Surgery is one of several treatments covered under Medicare. A procedure must be considered medically necessary to qualify for coverage. This means the surgery must diagnose or treat an illness, injury, condition or disease or treat its symptoms.

It’s difficult to determine exactly how much you’ll owe out-of-pocket because so many factors influence surgery cost.

Original Medicare coverage is split into Parts A and B. Part A will cover inpatient surgeries and hospital stays, while Part B covers outpatient procedures. Your Medicare coverage and out-of-pocket costs are different for inpatient and outpatient surgeries.

Just because you receive surgery in a hospital does not mean that you are by default considered inpatient. Whether you are an inpatient or outpatient can play a dramatic role in your costs.

It is important to make sure that 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. If your doctor does not accept Medicare, you may have to pay the entire cost.

Original Medicare covers many surgeries and procedures. The guiding principle is that they must be medically necessary procedures. If a surgery is critical to your health or wellbeing, then Medicare will typically cover it.

Outpatient surgery refers to a procedure a doctor performs without formally admitting you into the hospital. Outpatient procedures usually take place in a doctor’s office, an ambulatory surgical center or a hospital.

Medicare Part B covers outpatient surgery. Typically, you pay 20% of the Medicare-approved amount for your surgery, plus 20% of the cost for your doctor’s services.

The Part B deductible applies ($240 in 2024), 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% 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% 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 ($1,632 in 2024).

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.

As outpatient surgery grows more popular in the United States., 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 CMS outpatient payment rule added 267 additional procedures eligible for reimbursement, which started in 2021.

As is clear, where your outpatient surgery takes place matters and can significantly impact your out-of-pocket costs.

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 $1,632 for a stay of up to 60 days.

You’ll also owe 20% of the doctor’s charges.

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 $1,632 Part A deductible again.

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 $1,632 in 2024.

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.

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 also 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.

While it’s important to get an estimate in advance of non-emergency surgery, it’s also important to understand that estimates are not always accurate. In fact, according to Kaiser Health News, hospital estimates are often inaccurate and there is no legal obligation that they be correct.

But 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.

A surgery must be considered medically necessary to qualify for Medicare coverage.

Investigational procedures typically aren’t covered.

Medicare generally won’t cover cosmetic surgery either unless it repairs an accidental injury or improves the function of a malformed body part.

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 does cover breast reconstruction procedures following a mastectomy or lumpectomy. Medicare doesn’t consider these procedures to be cosmetic surgeries.