Does Medicare Cover Surgeries? A Look at Your Options

Medicare, the federal health insurance program, provides healthcare coverage for millions of Americans aged 65 or older, as well as certain younger individuals with disabilities. A common concern for beneficiaries is understanding how Medicare covers surgical procedures, which can be a substantial healthcare expense. The program assists with a wide range of medical services, including necessary surgeries, but the extent of coverage and associated costs depend on the specific parts of Medicare an individual has.

Original Medicare Coverage for Surgeries

Original Medicare consists of two primary parts: Part A (Hospital Insurance) and Part B (Medical Insurance). Part A primarily covers inpatient hospital care, including surgical procedures performed during a hospital admission. This encompasses costs associated with the hospital stay, such as the hospital room, nursing care, operating room use, and recovery room services. Drugs administered during the inpatient stay and meals are also covered under Part A.

Part B covers outpatient medical services and supplies. For surgeries, Part B covers the professional fees of the surgeon, anesthesia services, and pre- and post-operative doctor visits. It also includes coverage for surgeries performed in an outpatient setting, such as an ambulatory surgical center or a hospital outpatient department. Durable medical equipment (DME), like a walker or wheelchair, prescribed for use at home during recovery, also falls under Part B coverage.

Understanding Your Out-of-Pocket Costs

While Original Medicare provides coverage for surgeries, beneficiaries are responsible for certain out-of-pocket costs. For inpatient hospital stays covered by Part A, a deductible applies per benefit period. In 2025, this Part A deductible is $1,676. A benefit period starts the day a patient is admitted to a hospital or skilled nursing facility and ends after 60 consecutive days without inpatient care.

Beyond the deductible, coinsurance applies for longer inpatient stays. For hospital days 61 through 90 in a benefit period, the daily coinsurance is $419. If a stay extends beyond 90 days, beneficiaries use their limited “lifetime reserve days,” each incurring a daily coinsurance of $838.

For Part B services, an annual deductible applies. In 2025, this annual deductible is $257. After meeting this deductible, beneficiaries typically pay 20% of the Medicare-approved amount for most Part B services, including surgeon’s fees and outpatient surgery costs.

Medicare Advantage Plans and Surgery Coverage

Medicare Advantage plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans are required to cover at least the same benefits as Original Medicare, including medically necessary surgeries. Unlike Original Medicare, Medicare Advantage plans often have different cost-sharing structures, such as specific copayments or coinsurance for various services, including inpatient hospital stays or outpatient surgical procedures.

These plans may also feature network restrictions, meaning beneficiaries might need to use in-network providers (e.g., HMOs, PPOs). Referrals from a primary care physician may be required for specialist visits or surgeries. Many Medicare Advantage plans require prior authorization for certain surgeries or procedures. A significant benefit of Medicare Advantage plans is the annual out-of-pocket maximum, which caps the total amount a beneficiary pays for covered services in a year, offering financial protection against high medical costs.

Key Factors Affecting Coverage

Whether a surgery is covered by Medicare, either Original or Advantage, depends on several criteria. Foremost is medical necessity; Medicare only covers surgeries deemed necessary to diagnose or treat an illness, injury, condition, or its symptoms. Purely cosmetic procedures or experimental surgeries not approved by Medicare are generally not covered.

For some surgeries or procedures, particularly under Medicare Advantage plans, prior authorization may be a requirement. This process involves the healthcare provider obtaining approval from Medicare or the plan before the procedure is performed, confirming medical necessity and the appropriate setting for care. Beneficiaries should ensure prior authorization is secured to avoid unexpected costs.

It is also important to choose healthcare providers who “accept assignment,” meaning they accept the Medicare-approved amount as full payment for their services. This helps limit out-of-pocket expenses, as providers who do not accept assignment can charge up to 15% more than the Medicare-approved amount. Discussing coverage details with both the healthcare provider and the Medicare plan administrator before a scheduled surgery is always advisable.