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The cost of hospital care can be daunting. Fortunately, if you have Medicare Part A (hospital insurance) and Part B (medical insurance) may cover many inpatient health-care services, including most inpatient surgery.
What is an inpatient surgery?
Inpatient surgery refers to surgery performed in the hospital after a doctor has admitted you as an inpatient. Your doctor may order an inpatient surgery during a hospital stay or may schedule surgery in advance of your hospital admission.
It is important to understand that you can be getting care in a hospital and still be an outpatient, not an inpatient. Your Medicare coverage and out-of-pocket costs are different for outpatient and inpatient surgery.
When does Medicare cover inpatient surgery?
Your inpatient surgery must meet two basic requirements for Medicare coverage:
- The hospital and physicians performing the inpatient surgery accept Medicare
- Inpatient surgery must be medically necessary. Medicare defines “medically necessary” as “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
- In certain cases, the Utilization Review Committee of the hospital approves your stay while you’re in the hospital.
If you’re enrolled in a Medicare Advantage plan, the plan may also require the hospital and doctors providing inpatient surgery to participate in the plan’s provider network as a condition of coverage.
If your inpatient surgery meets Medicare requirements, Medicare Part A and Medicare Advantage plans typically pay for covered hospital services. Hospital services related to inpatient surgery usually include daily room and board, laboratory services, diagnostic tests, surgical equipment and supplies, anesthesia, and the services of doctors, nurses, and other health professionals.
Medicare Part B and Medicare Advantage plans generally cover physician services, including surgeons and anesthesiologists who participate in the inpatient surgery but who are not employees of the hospital.
What can you expect to pay for an approved inpatient surgery?
Medicare Part A generally covers much of the cost related to your inpatient surgery and hospital stay. You may be responsible for a Medicare Part A deductible ($1,364 in 2019) for each benefit period. Medicare defines a benefit period as beginning the day you’re admitted as an inpatient in a hospital or skilled nursing facility (SNF) and ending when you have not received any inpatient hospital or SNF care for 60 days in a row. You pay this inpatient hospital deductible amount for each benefit period.
The amount you may pay for inpatient surgery can also depend on your recovery time. You won’t typically pay a Medicare Part A coinsurance amount if your inpatient stay lasts between one and 60 days. However, if you spend more time in the hospital for inpatient surgery, you have to pay a coinsurance amount.
- You will pay $341 per day (in2019) per benefit period for days 61 to 90.
- You will be liable for $682 (in 2019) per benefit period for every “lifetime reserve” day you spend in the hospital beyond 90 days.
- If you are still in the hospital after exhausting your “lifetime reserve days,” Medicare Part A generally will not continue coverage for your hospital expenses.
Medicare Part B usually pays 80 percent of the Medicare-approved amount for doctors’ services billed separately from the hospital’s charges for inpatient surgery. You are responsible for 20% after you have met the Part B annual deductible ($185 in 2019).
If you have a Medicare Supplement (Medigap) plan, it may cover some out-of-pocket costs related to your inpatient surgery. All of the Medicare Supplement plans standardized in 47 states may pay the Part A coinsurance on long hospital stays (for an additional 365 days after Medicare coverage is used up). Many also cover all or a portion of Part B coinsurance and Part A and Part B deductibles.
If you have a Medicare Advantage plan, specific inpatient deductibles, coinsurance, and copayments for inpatient surgery may be different from Medicare Part A and Part B cost shares. You can contact the plan’s customer service for coverage information.
Would you like to learn more about Medicare coverage of inpatient surgery or your Medicare coverage options? I would be happy to help you.
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