Does Medicare Cover Hernia Surgery?
How do you know if you may have a hernia? When tissue or an organ pushes through the surrounding muscle wall, you may experience any of the following common symptoms:
- An abnormal bulge or lump in the area where the hernia is located
- Pain or discomfort in the area where the hernia is
Hernias are more common for men than women and they can occur due to muscle weakness, injury, prior surgical procedures, aging, chronic coughing, weightlifting, or overstraining during physical activity.
Unfortunately, once you have a hernia, it won’t get better on its own. Depending on the type of hernia and its severity, it can even be life-threatening. For this reason, if you suspect you have a hernia, you should see your health care provider immediately. If you have a hernia, your physician may suggest surgery.
How does Medicare cover hernia surgery?
Medicare typically covers hernia surgery if your health care provider certifies that it is a medically necessary procedure. If you have coverage through Original Medicare Part A (inpatient hospital insurance) and Part B (outpatient medical insurance), your coverage depends on how you have your surgery.
Original Medicare Part A covers your hernia procedure if you are formally admitted to the hospital. This may be necessary if you are having open surgery instead of laparoscopic surgery. The decision your surgeon makes depends on the location of your hernia and your overall health. During open surgery, the surgeon makes an incision close to the site of the hernia, pushes the tissue or organ back into place, and stitches the muscle wall closed. In some cases, a surgical mesh is placed along the muscle wall for reinforcement of the site.
Original Medicare Part A pays for your surgical procedure and hospital stay if you are admitted to a hospital that accepts Medicare assignment. You are responsible for paying the Part A deductible for the current benefit period before the surgery. As of 2022, the Part A deductible is $1,556.00.
Original Medicare Part B covers medically necessary hernia surgery if you have the procedure done while you are an outpatient in a medical facility that accepts Medicare assignment.
As an outpatient, you might have a laparoscopic hernia procedure which is less invasive. For this type of procedure, the surgeon makes small incisions around the site of the hernia, inserts cameras, and uses mechanical equipment to stitch up the muscular wall where the tear has occurred.
Original Medicare Part B covers 80 percent of the cost of your hernia procedure as an outpatient. You are responsible for the remaining 20 percent after meeting your annual Part B deductible.
How Medicare Advantage plans cover hernia surgery
If you have a Medicare Advantage (Part C) plan,your provider must provide the same, at minimum, the coverage that you would have through Original Medicare Parts A and B. So, if you meet Medicare’s eligibility requirements for hernia surgery, your Part C plan must cover it.
How much you pay out-of-pocket for coinsurance or copayments depends on your individual Medicare Advantage plan. Depending on the type of Medicare Advantage plan you have, you may be required to use physicians, surgeons, other health care providers, hospitals, or other medical facilities that your plan includes in its set network of providers. You may also need to get a referral from your primary care provider before seeing a specialist.
If you aren’t sure about what restrictions your Part C plan includes, you should contact your provider for more details before making any appointments.