When it comes to surgical procedures, both Medicare and Medicaid provide coverage for many medically necessary surgical services received under inpatient and outpatient treatment. However, coverage terms can vary depending on the type of surgery being performed, where it is performed, and your specific circumstances.

Understanding Different Types of Surgeries

The Medicare and Medicaid programs determine coverage according to what operation is performed and the medical condition it treats. These procedures may require inpatient admittance to a hospital for one or several nights, or they may be performed at an outpatient surgical center that allows you to return home on the same day as the procedure.

Knowing how these three categories of surgery are defined can help you know if your benefits include coverage for it:

  • Emergency. In emergency surgery situations, operations are performed to prevent a loss of life or significant illness or injury. The patient’s symptoms are considered acute and may be caused by sudden trauma or a preexisting condition.
  • Elective. These procedures treat conditions that are not life threatening but may still be needed to improve a chronic medical condition that restores function or improves the patient’s quality of life.
  • Cosmetic. Many cosmetic procedures focus on changing a patient’s appearance as a way of improving self-esteem or satisfying a personal preference, but these operations can also restore damaged tissue due to trauma or defect.

In almost every case, an emergency surgery qualifies for coverage through Medicaid services. If an elective or cosmetic surgery is deemed medically necessary, it can also be approved. The rules for what counts as medically necessary are defined by each state’s administrating agency and may differ from a physician’s definition of medical necessity.

Coverage for Medicare-Medicaid Dual-Eligibles

Although Medicare covers many of the same surgeries as Medicaid, there can be extra costs that may become a financial burden for low-income beneficiaries. Recipients qualify for Medicaid services as dual-eligibles when they meet their state’s income and asset limits for the program.

Different levels of eligibility receive different benefits that can help reduce Part A or Part B expenses. When approved, Medicaid can help cover the costs of Part A or Part B’s premiums in addition to their associated co-payments, coinsurances and deductibles. If a hospital stay for surgery lasts longer than Medicare Part A’s limit, Medicaid coverage may provide benefits for the remainder of the time.

Each state must provide the services that the federal Medicaid agency describes as mandatory, but some diagnostic procedures and certain treatments may fall under optional coverage rules. It’s important to discuss any treatment plan with your health care team so that you can understand what may or may not be covered by your dual-eligibility for Medicare-Medicaid services. This can help you avoid unwanted or unexpected out-of-pocket costs.

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