How Does Medicare Cover Surgeries?

Generally speaking, Medicare covers nearly all medically necessary services, including surgeries. However, there are two parts of Medicare (Part A and Part B), and the type of surgery you’re having will dictate how Medicare covers the surgery.

Surgeries Under Part A vs Part B

If you have surgery while spending time in the hospital as an inpatient, Part A might cover the surgery. (Hence, we often refer to Part A as “inpatient” insurance.) On the other hand, if the surgery is considered an outpatient procedure, it will fall under Part B, which provides outpatient medical benefits.

Surgeries that fall under Part B will require you to pay the annual Part B deductible (unless you’ve already met it for the year), as well as a 20% coinsurance cost. There is no cap on that 20% coinsurance, so your portion can get rather expensive very quickly.

We urge all of our clients to have more than just Original Medicare coverage. You can add either a Medigap plan or a Medicare Advantage plan to potentially lower your out-of-pocket costs if you need surgery while under Medicare.

Medigap plans are the best way to keep your out-of-pocket expenses low. For example, if you have Plan G, you’ll only owe the Part B deductible each year. The 20% coinsurance that would have been your responsibility is covered by Plan G. The same is true of other popular Medigap plans in Arizona, including Plan F and Plan N.

Medical Necessity: The Key to Coverage

Medicare will not cover any surgeries that aren’t medically necessary. It won’t pay for surgeries done for cosmetic reasons or if they’re related to what Medicare considers “routine care,” like a surgery related to routine foot care. And if Original Medicare does not approve the surgery, neither will your Medigap plan. If Medicare denies the claim, your Medigap plan will also deny the coverage it otherwise would have offered.

Medicare and Oral Surgery

Medicare doesn’t have a great track record of covering and dental care, including oral surgery. There are very few instances when Medicare will cover dental services. In most cases, those instances must relate to broken or fractured jaws, radiation, or active infections prior to cardiac surgery.

Many Medicare Advantage plans include routine dental benefits, which is one reason many people are attracted to Medicare Advantage plans. However, this should not be the only reason you decide to enroll in Medicare Advantage. Carefully review the plan’s medical benefits, as those are often the most costly.

Get Medicare Guidance for Your Surgery

Need help finding out if Medicare will cover your surgery? Chat with one of the advisors at Local Medicare Specialists. We can look at your specific Medicare plans and help you read through the benefits to find out if your surgery is covered and, if so, how much you’ll owe.