Does Medicaid Cover Surgery?

When your doctor determines that you need surgery to ease symptoms of a condition or treat a disease, the last thing you want to worry about is how you'll afford the procedure that you need. Understanding how Medicaid covers surgery can ease some of the stress by making it easier to predict how much of the cost of the procedure may be your responsibility.

When Does Medicaid Cover Surgery?

Under federal law, Medicaid must provide general coverage for inpatient and outpatient treatment in a hospital. As a result, at least some surgeries are covered in every state. Your state's Medicaid plan can establish its own rules regarding which procedures are covered and what costs can be passed on to you.

For specific information about Medicaid coverage for surgery, you can consult your state's site. You can also discuss coverage with your medical provider.

Coverage for Surgery by Type

Generally, surgical procedures fall under three categories, and Medicaid programs tend to treat each type differently.

Emergency Surgery

Emergency surgery is a procedure that is necessary to save a person's life or to prevent serious damage or injury to the body. This type of surgery often needs to be performed suddenly and may be required after an accident or due to trauma or a preexisting condition that worsens unexpectedly. Typically, Medicaid covers emergency surgery.

Elective Surgery

Elective surgery is a procedure performed to improve a person's quality of life or to allow them to more easily perform daily living tasks. Their condition isn't life-threatening, but the doctor testifies to the fact that it's medically necessary. In most cases, Medicaid covers elective surgery; however, states may require the person to meet certain health criteria to qualify for coverage.

Cosmetic Surgery

Cosmetic surgery is a procedure that improves a person's appearance. Although the procedure may benefit mental health by improving self-esteem, it is not considered medically necessary. Medicaid programs are less likely to cover cosmetic surgery, and states may make an exception for certain procedures. For example, breast reconstruction surgery after a mastectomy to treat breast cancer is covered in some states.

Copays and Coinsurance for Surgery Under Medicaid

Even if the surgery is covered by Medicaid, you may have to pay for part of the procedure. State programs can require a copay or coinsurance. For example, in Alabama, Medicaid recipients are assessed a flat fee of $50 every time they are admitted to the hospital, and in Georgia, enrollees pay a $12.50 copay for hospital stays, according to the Kaiser Family Foundation. Some states like Montana base copays on income.

How Much Does Medicare Pay for Surgery?

As with Medicaid, Medicare typically only covers medically necessary surgery. You'll usually have to meet certain qualifications to receive coverage. Under Original Medicare, what amount you pay toward surgery depends on whether the procedure is performed on an in-patient or outpatient basis.

• Inpatient surgery falls under Medicare Part A, which pays most of the cost. You are usually responsible for a monthly premium and must satisfy a deductible before Medicare Part A will cover the surgery. Depending on the length of your hospital stay, you may also need to pay a copay or coinsurance.
  
  
• Outpatient surgery is covered through Medicare Part B. Like Medicare Part A, Part B usually has a monthly premium and a deductible. Through this portion of Medicare, you're typically responsible for 20% of the cost of care with your plan paying the remainder.

Medicare Advantage Plans must cover at least as much as Original Medicare but can extend their list of covered services to procedures that Parts A and B don't pay for.

If you have Medicare Part C, you'll usually have a monthly premium and deductible to pay. Most plans also charge a copay or coinsurance for covered surgery. Your plan may require you to choose a doctor, a hospital or an outpatient surgical center within a preset network.

What Medical Expenses Are Not Covered by Medicare?

If a surgical procedure isn't covered by Medicare, you'll have to pay for it out of pocket. Generally, Medicare doesn't cover expenses that:

• Are associated with clinical trials
• Are not backed by medical science
• Are not medically necessary
• Include the use of medical devices or equipment not approved by the U.S. Food and Drug Administration

Even for covered services, you're likely to still be responsible for paying:

• Annual deductibles
• Copays or coinsurance
• Monthly premiums

Medicaid and Medicare Dual Eligibility

If you're on Medicare and are eligible for Medicaid, your state's Medicaid program may help you pay for certain Medicare costs such as:

• Coinsurance
• Copays
• Deductibles
• Premiums

When you're enrolled in both Medicare and Medicaid, Medicare usually pays first, and Medicaid then helps to pay for all or some of what's not covered.

For example, if you require a lengthy stay in a hospital following surgery, Medicaid Part A would pay the daily cost of your stay up to a preset limit. Then, Medicaid would usually cover all or some of the cost of the remaining days. Your Medicaid plan may also help you pay for the deductible and coinsurance associated with Medicare Part A.