Does Medicare Cover Hernia Surgery Costs?

Hernia surgery is a common medical procedure. For individuals relying on Medicare for their healthcare needs, understanding the scope of coverage is important. Medicare generally provides coverage for medically necessary services, which often includes hernia repair. This article details how Medicare addresses the costs associated with hernia surgery, helping beneficiaries make informed decisions about their care.

Medicare’s General Approach to Hernia Surgery

Medicare covers hernia surgery when a healthcare provider determines it is medically necessary. This means the procedure is required to diagnose, treat, or manage a condition or its symptoms, and it aligns with accepted standards of medical practice. A hernia occurs when an organ or fatty tissue pushes through a weak spot in a surrounding muscle or connective tissue, often creating a visible bulge.

Common types of hernias that typically meet Medicare’s medical necessity criteria for surgery include inguinal hernias, which affect the groin area, umbilical hernias near the belly button, and incisional hernias that can occur at the site of a previous surgical incision. Surgical approaches vary and can include open repair, laparoscopic repair, or robotic repair. Medicare does not cover elective or cosmetic hernia repairs, as these lack a clear medical need.

Coverage Under Original Medicare Parts A and B

Original Medicare, which consists of Part A (Hospital Insurance) and Part B (Medical Insurance), provides distinct coverage for medically necessary hernia surgery depending on where the procedure takes place.

Medicare Part A covers inpatient hospital services. If hernia surgery requires an overnight stay in a hospital, Part A pays for costs such as the semi-private room, meals, general nursing care, and any medications or medical supplies received during the inpatient stay. Part A may also cover skilled nursing facility care if medically necessary after the surgery for recovery, and certain home health services.

Medicare Part B covers medical services and supplies provided on an outpatient basis. This includes the surgeon’s fees, anesthesiologist’s fees, and services received in an outpatient surgery center or a hospital’s outpatient department. Part B also covers diagnostic tests, such as imaging or lab work, performed before or after the surgery. Outpatient physical or occupational therapy, if prescribed as part of recovery, would also fall under Part B coverage.

Medicare Advantage Plans and Hernia Surgery

Medicare Advantage (MA) plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans must provide at least the same level of coverage as Original Medicare Parts A and B, meaning medically necessary hernia surgery is covered under an MA plan.

MA plans often have different rules and cost structures compared to Original Medicare. Many MA plans utilize provider networks, meaning beneficiaries may need to receive care from doctors and facilities within the plan’s network to ensure full coverage and lower out-of-pocket costs. Some plans may require referrals from a primary care physician to see specialists or undergo surgery. Prior authorization is a common requirement with MA plans, where the plan needs to approve the surgery before it is performed. Prior authorization ensures the service is medically necessary and aligns with the plan’s coverage guidelines.

Understanding Your Financial Responsibility

Beneficiaries will incur out-of-pocket costs for hernia surgery, including deductibles, coinsurance, and copayments, regardless of whether they have Original Medicare or a Medicare Advantage plan.

Under Original Medicare, the Part A deductible for inpatient hospital stays is $1,676 per benefit period in 2025. A benefit period begins when you are admitted to a hospital or skilled nursing facility and ends after you have been out for 60 consecutive days. For Part B services, there is an annual deductible, which is $257 in 2025. After meeting the Part B deductible, beneficiaries are typically responsible for 20% coinsurance of the Medicare-approved amount for most services, such as surgeon’s fees and outpatient facility charges. Original Medicare does not have an annual out-of-pocket spending limit.

Medicare Advantage plans have their own cost-sharing structures, which can include varying deductibles, copayments, and coinsurance amounts for services. For example, an MA plan might have a fixed copayment for an outpatient surgery rather than a 20% coinsurance. MA plans have an annual out-of-pocket maximum for Part A and B covered services. In 2025, this limit cannot exceed $9,350 for in-network services, though many plans set lower limits. Once this maximum is reached, the plan pays 100% of covered services for the remainder of the calendar year.