How Does Medicare Cover Surgery? 

Surgery has been practiced in the medical field for thousands of years, and today, surgical techniques and equipment are more sophisticated than ever. Modern surgical procedures are safer than ever and include the use of sophisticated equipment, including robotics using remote guidance technology. Surgery can be a medically necessary solution to a patient’s needs, but Medicare may cover it different ways. Coverage may depend on the reason for surgery and where you have the procedure performed. 

When is surgery considered medically necessary? 

Surgery is performed for a wide range of injuries or illnesses. Surgery is typically a last resort when other more conservative measures have failed. Coverage for some procedures may be based on whether other treatments or medications have been ineffective in solving your medical issue. Some procedures are unavoidable.

Surgery may be recommended in cases where treatment with medications is not enough or when surgery is the most efficient method of treatment. Doctors may also recommend surgery in emergencies when conservative methods of treatment may not be expedient given the nature or severity of an illness or injury.

Surgery is performed on people of all ages, but surgery for seniors requires special considerations. Because surgery can be quite taxing on the body, seniors often need a comprehensive evaluation before procedures are to be performed to ensure surgery can be carried out safely. Prior to ordering surgery, your doctor will evaluate your health and order diagnostic tests as needed to ensure the procedure can be completed safely.

If your physician deems the surgery to be medically necessary, Medicare may help cover the costs of your care. 

How does Medicare cover surgery?

Seniors and people under 65 who qualify due to disabilities in the United States can turn to Medicare benefits to provide coverage for many surgical procedures. Medicare covers surgery through Part A or Part B.

If the surgery takes place in an outpatient setting, Part B will help cover your care. The outpatient portion of Medicare insurance offers coverage for surgery that takes place in a doctor’s office or outpatient clinic. Part B also includes coverage for diagnostic testing, durable medical equipment, pre-op and post-op doctor visits and clinical treatment. Medicare Part B may also provide coverage for some home health care and physical therapy following surgery to aid in your recovery and rehabilitation. 

If your surgery takes place after you’ve been formally admitted into a hospital, Part A may apply. If you have questions about your surgery setting, talk to your doctor for the details.

How do Medicare benefits cover surgery?

Medicare Part B pays for 80% of surgical costs while Medicare recipients cover a 20% coinsurance. Most people pay a monthly premium for Part B benefits and a yearly deductible applies. There is no limit to the number of covered surgeries you can have performed, but in order to receive coverage, a surgical procedure must be ordered by a Medicare-participating physician.

Surgery must be a medical necessity in order to qualify for Medicare coverage. This means that elective surgery, cosmetic surgery and surgery for weight loss are not covered by Medicare benefits. However, if weight loss or cosmetic enhancement are side effects of a surgical procedure, that procedure may still qualify for Medicare coverage as long as the purpose of the surgery is borne out of medical necessity.

How much does Medicare Part B cost?

Medicare Part B requires a monthly premium. This cost can vary based on your income level and tax filing status. In 2024, Medicare recipients who file as single individuals and have an annual income of $103,000 or less will pay $174.70 per month for Medicare Part B. Married individuals filing a joint tax return who have an income of $206,000 or less will pay $174.70 as well.

These costs go up as your income level rises. Medicare recipients who have an income of $500,000 as single tax filers or $750,000 as married and filing jointly will be assessed an income-related monthly adjustment amount (IRMAA) of $419.30, bringing the total monthly premium for Part B to $594.

Medicare insurance also requires that recipients meet a deductible in order to utilize Part B benefits. This is the amount in outpatient costs that must be accrued by Medicare recipients prior to benefits applying toward costs. For 2024, this amount is $240.

Most people receive Part A premium-free due to taxes paid while working, but an annual deductible applies. In 2024, the Part A deductible is $1632. Days 1-60 in the hospital cost $0. Costs go up based on the number of days you remain hospitalized. 

Coverage for medications prescribed post-surgery

Medications prescribed by your physician after surgery may be covered by Medicare Part D. Part D is the prescription drug benefit. It is optional coverage, but most people choose to enroll when they’re first eligible unless they have other creditable coverage. You’ll likely pay a monthly premium for Part D coverage. Plans will vary in costs. Plans each have their own formulary, or list of covered drugs. Check with your plan directly for specific information. 

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