Medicare generally covers hemorrhoid surgery, provided the procedure is medically necessary. Hemorrhoids are swollen veins in the lower rectum and anus, categorized by severity using a grading scale. When conservative treatments like dietary changes, medications, or office-based banding procedures are unsuccessful, surgical intervention may be required. Common surgical options include rubber band ligation, coagulation therapy, and the more invasive hemorrhoidectomy or hemorrhoidopexy for advanced cases. These procedures are covered services, although specific out-of-pocket costs will vary.
Coverage Under Original Medicare
Original Medicare, which consists of Part A (Hospital Insurance) and Part B (Medical Insurance), covers medically necessary hemorrhoid surgery. The coverage component depends on the setting where the procedure is performed. Part A covers costs if the procedure requires an inpatient hospital stay, such as the facility, room, and nursing care. However, this is uncommon for most hemorrhoid surgeries.
Most hemorrhoid surgical interventions are performed on an outpatient basis in a doctor’s office, ambulatory surgical center, or hospital outpatient department. Part B covers these costs, including the physician’s professional fees, facility charges, supplies, equipment, and necessary pre- and post-operative services. Coverage for specific procedures is often tied to the severity of the hemorrhoids and whether prior conservative treatments failed.
Financial Responsibility and Co-Payments
While Original Medicare covers the bulk of the cost for medically necessary hemorrhoid surgery, beneficiaries are responsible for certain out-of-pocket expenses. If the surgery requires a rare inpatient stay, the patient must first pay the Part A deductible per benefit period. Coinsurance payments would apply if the inpatient stay extended beyond 60 days in a benefit period.
For the more typical outpatient surgery, the patient is responsible for the annual Part B deductible before coverage begins. After meeting this yearly deductible, the patient generally pays a coinsurance amount equal to 20% of the Medicare-approved amount for the procedure.
This 20% coinsurance applies to the full cost of the outpatient service, including the doctor’s fees and the facility charges. For example, for an outpatient rubber band ligation with a total Medicare-approved amount of $380, the average patient responsibility after the deductible is met is about $76. Because there is no annual out-of-pocket maximum under Original Medicare, a patient’s financial responsibility for multiple or high-cost procedures can accumulate quickly.
Coverage Through Alternative Medicare Plans
Beneficiaries can choose alternative Medicare plans that modify how hemorrhoid surgery is covered and what the patient pays. Medicare Advantage (Part C) plans are offered by private insurance companies and must cover all the same services as Original Medicare, including medically necessary hemorrhoid surgery. However, these private plans set their own cost-sharing rules, which can include different deductibles, copayments, and coinsurance amounts than Original Medicare.
Medicare Advantage plans often require the use of in-network providers and may necessitate prior authorization for surgical procedures. A significant difference from Original Medicare is that Part C plans include an annual out-of-pocket maximum, which limits the total amount a beneficiary must pay for covered services in a year. This maximum provides a financial safeguard that Original Medicare does not offer.
Medigap (Medicare Supplement Insurance)
Medigap works differently by helping to cover the out-of-pocket costs associated with Original Medicare. These standardized policies are sold by private companies and are specifically designed to pay for the deductibles, copayments, and coinsurance amounts that are the patient’s responsibility under Parts A and B. Medigap plans do not replace Original Medicare but rather work alongside it to reduce the beneficiary’s financial burden.