How Much Does Medicare Cover for Surgery?

Medicare, a federal health insurance program, helps millions of Americans manage their healthcare costs as they age or face certain disabilities. Understanding how Medicare covers surgical procedures is important for beneficiaries to anticipate their financial responsibilities. Surgical costs can vary significantly, depending on the specific type of procedure, where it is performed, and the particular Medicare coverage an individual has chosen. Navigating these complexities involves distinguishing between different Medicare options and how each addresses various components of a surgical event.

Original Medicare Coverage for Surgery

Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), forms the foundation of coverage for many surgical procedures. These two parts address distinct aspects of care, and their roles depend heavily on whether a surgery is performed on an inpatient or outpatient basis.

Medicare Part A primarily covers inpatient hospital care, including surgery performed when a beneficiary is formally admitted to a hospital. This coverage extends to facility fees, nursing care, laboratory tests, and medications received during an inpatient stay. For each benefit period, beneficiaries are responsible for a Part A deductible, which is $1,632 in 2024. If an inpatient stay extends beyond 60 days in a benefit period, a daily coinsurance applies; this amount is $408 per day for days 61-90 and $816 per day for lifetime reserve days (up to 60 days over a lifetime) in 2024.

Medicare Part B covers medical services and supplies, including most outpatient surgical procedures, doctor’s services, and diagnostic tests. This part specifically covers the professional fees for surgeons and anesthesiologists, regardless of whether the surgery is performed inpatient or outpatient. Part B also helps cover durable medical equipment and certain medical supplies related to surgery. For Part B services, beneficiaries pay an annual deductible, which is $240 in 2024. After meeting this deductible, Medicare generally pays 80% of the Medicare-approved amount for most covered services, leaving the beneficiary responsible for the remaining 20% coinsurance.

The setting of care determines which part covers facility costs. If a surgery requires an overnight hospital stay and a formal inpatient admission, Part A typically covers the facility. If performed in an outpatient setting, such as a hospital outpatient department or an ambulatory surgical center, Part B covers facility costs. Regardless of the setting, Part B consistently covers the professional fees of surgeons, anesthesiologists, and other doctors involved. Original Medicare does not impose an annual out-of-pocket maximum.

Medical necessity governs Medicare coverage. Services and supplies are covered only if they are “medically necessary,” meaning they are needed to diagnose or treat an illness, injury, condition, or disease and meet accepted standards of medicine. If a procedure is not deemed medically necessary, Medicare will not cover it, making the beneficiary responsible for the full cost. This determination is made by Medicare based on established guidelines and the provider’s documentation.

Medicare Advantage Plans and Surgical Procedures

Medicare Advantage Plans, also known as Medicare Part C, are an alternative way to receive Medicare benefits. These plans are offered by private insurance companies that are approved by Medicare, and they are required to cover all the services that Original Medicare (Parts A and B) covers. Many Medicare Advantage plans also provide additional benefits not included in Original Medicare, such as vision, hearing, or dental care.

Medicare Advantage plans often have network requirements, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). These may limit the choice of providers for surgical procedures. Choosing out-of-network providers in a PPO plan, or any provider outside the network in an HMO plan (except for emergencies), can result in higher out-of-pocket expenses or no coverage.

Medicare Advantage plans establish their own deductibles, copayments, and coinsurance amounts for surgical procedures, which can vary significantly from one plan to another. Unlike Original Medicare, all Medicare Advantage plans include an annual out-of-pocket maximum for Part A and B services. Once a beneficiary reaches this limit, the plan pays 100% of covered services for the remainder of the calendar year, providing a financial safety net. For 2024, this maximum cannot exceed $8,850 for in-network services.

Many Medicare Advantage plans require prior authorization for surgeries and certain other services. Failure to obtain this authorization before a procedure can lead to increased costs or denial of coverage. Some plans may also require referrals from a primary care physician to see specialists or undergo surgery. Beneficiaries should review their plan’s Evidence of Coverage to understand its cost-sharing, network rules, and authorization requirements.

Medigap Policies and Surgery Costs

Medigap, or Medicare Supplement Insurance, policies are sold by private companies and are designed to help pay some of the out-of-pocket costs that Original Medicare does not cover. These policies work in conjunction with Original Medicare, meaning a beneficiary must be enrolled in both Medicare Part A and Part B to purchase a Medigap plan. If a surgery is covered by Original Medicare, a Medigap policy will then help cover the remaining costs.

Medigap policies can significantly reduce a beneficiary’s financial exposure by covering expenses such as the Medicare Part A deductible, Part B coinsurance, and Part A coinsurance for extended hospital stays. For example, Medigap Plan G covers the Part A deductible ($1,632 in 2024) and the 20% Part B coinsurance. This means that after Original Medicare pays its share, the Medigap policy covers much of the remaining approved costs, providing more predictable expenses for surgical procedures.

Medigap plans are standardized across most states, labeled by letters A through N. This means a Plan G from one insurer offers the same basic benefits as a Plan G from another, though premiums vary. Medigap policies work with any doctor, hospital, or other healthcare provider nationwide who accepts Medicare, offering broad flexibility and no network restrictions. This is beneficial for individuals who travel or prefer to choose their providers without limitations.

Medigap policies cannot be used if a person has a Medicare Advantage Plan. They are designed to supplement Original Medicare. Beneficiaries must choose between enrolling in a Medicare Advantage Plan or staying with Original Medicare and potentially purchasing a Medigap policy.

Your Potential Out-of-Pocket Expenses

Even with Medicare coverage, beneficiaries will likely incur out-of-pocket expenses for surgical procedures. These costs typically include deductibles, copayments, and coinsurance. A deductible is the initial amount a beneficiary must pay for covered services before Medicare or their plan begins to pay. For example, in Original Medicare Part B, the annual deductible is $240 in 2024.

Coinsurance represents a percentage of the cost of a service paid after the deductible has been met. With Original Medicare Part B, beneficiaries are responsible for 20% of the Medicare-approved amount for most services. Copayments are fixed amounts paid for specific services, more common in Medicare Advantage plans. These cost-sharing mechanisms directly contribute to a beneficiary’s total financial responsibility.

Certain services are not covered by Medicare, and beneficiaries are responsible for 100% of these costs unless other supplemental insurance applies. This includes procedures deemed not medically necessary, such as purely cosmetic surgeries like a tummy tuck or breast augmentation not related to a mastectomy. Experimental treatments are also typically not covered, though Medicare may cover routine costs associated with participation in approved clinical trials.

Balance billing is another potential out-of-pocket expense for those with Original Medicare. This occurs when a non-participating provider charges more than the Medicare-approved amount for a service. While providers who accept Medicare assignment cannot balance bill, non-participating providers may charge up to 15% above the Medicare-approved amount, known as the limiting charge. Medigap Plans F and G cover these Part B excess charges, providing financial protection. Beneficiaries should discuss estimated costs with their doctors and hospitals and verify coverage details with their Medicare plan provider before surgery.