Does Medicaid Cover Shoulder Surgery?

If your doctor has recommended surgical treatment for a shoulder injury or a chronic condition affecting your shoulders, you may be concerned about the cost of these procedures. Does Medicaid cover shoulder surgery? In most cases, the answer to this question will be yes.

Three Categories of Surgical Procedures

The Centers for Medicare & Medicaid Services (CMS) have established three basic categories into which surgical procedures generally fall:

• Emergency surgeries are usually performed in the hospital to treat serious injuries or illnesses and to protect the life of the patient. These surgical procedures are medically necessary and are performed to address acute issues immediately.
• Elective surgeries are less urgent and may be performed in the hospital or in a clinical setting. These surgical procedures are medically necessary to correct an issue or to improve the health and quality of life of the patient.
• Cosmetic surgeries are not medically necessary in most cases. These procedures are, instead, intended to improve the appearance to promote greater confidence and to improve the quality of life for the patient.

Medicaid considers the category into which the proposed surgery falls when determining whether it will cover a specific surgical procedure. In some cases, Medicare may pay for a certain portion of the surgery while denying coverage for other treatments associated with this procedure.

Medicaid Covers Only Medically Necessary Surgeries

You may have heard that Medicaid never covers cosmetic surgical procedures. This is not true. Medicaid does, however, only pay for cosmetic surgeries if they are deemed to be medically necessary or if they are classed as reconstructive surgeries after an injury or traumatic medical issue. As a general rule, Medicaid pays for nearly all emergency surgeries, some elective surgeries and few cosmetic procedures.

Does Medicaid Cover Shoulder Surgery?

Medicaid covers only medically necessary surgeries. Consider these three scenarios:

• If you are seriously injured in a car accident and require emergency shoulder surgery, it is very likely that Medicaid will pay for the cost of your surgical procedure.
• If you have chronic pain in your shoulder, your doctor may recommend an elective surgical procedure to correct this issue. Medicaid will evaluate the benefits and costs of the procedure before agreeing to pay for your surgery or denying your request.
• If you have a scar on your shoulder that affects your appearance, Medicaid will generally not pay for surgical removal or treatment of this cosmetic issue.

Medicaid is administered by the individual states. As a result, the types of treatment covered by Medicaid in your state may vary from those covered in other parts of the United States.

What If I Am Eligible for Medicare and Medicaid?

People who are eligible for both Medicare and Medicaid benefits may receive added benefits from the combination of these two programs. If you are a dual-eligible recipient of Medicare and Medicaid, you may be able to reduce your expenses under Medicare Part A or Part B. Medicaid can be used to reduce the amount you pay out of pocket for deductibles, copays and coinsurance requirements. Medicaid may also allow you to receive coverage for hospital stays that exceed the time limits of Medicare Part A.

Determining whether your shoulder surgery will be covered by Medicaid can help you make the most appropriate financial choices for yourself and your family. Consulting with your physician or your Medicaid advisor can help you determine whether your surgical procedure is likely to be paid for completely or in part by your Medicaid coverage.