A hernia is a common medical condition where an internal organ or tissue pushes through a weak spot in the surrounding muscle or tissue wall, most frequently occurring in the abdominal or groin area. This protrusion creates a bulge that can cause discomfort, especially during activities like coughing, straining, or heavy lifting. Surgery is the primary treatment for hernias that require intervention. Medicare generally covers the cost of hernia repair surgery, provided the procedure is determined to be medically necessary by a healthcare provider.
How Original Medicare Covers Hernia Surgery
Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), provides coverage for hernia surgery. The specific part responsible depends on the setting of the procedure. Since many hernia repairs are now performed in an outpatient setting, coverage most often falls under Medicare Part B. Part B covers the services received outside of an inpatient stay, such as the surgeon’s fees, anesthesia administration, and the use of an ambulatory surgical center or hospital outpatient department.
If the hernia repair is a more complex case requiring a hospital admission for an overnight stay, the facility costs are covered by Medicare Part A. This coverage includes the semiprivate room, meals, general nursing care, and the costs associated with the operating room while admitted as an inpatient. Part B covers necessary durable medical equipment or supplies used during the repair, such as surgical mesh. Part B also covers related services, including pre-operative consultations, diagnostic tests, and post-surgical follow-up appointments. The distinction between Part A and Part B coverage is strictly based on the patient’s admission status—inpatient versus outpatient.
Prerequisites for Coverage: Medical Necessity
Medicare’s coverage for hernia surgery is contingent upon a determination of medical necessity. A procedure is considered medically necessary if it is required to diagnose, treat, or manage a medical condition and meets accepted standards of medical practice. For a hernia, this means the condition is causing symptoms that interfere with daily life or poses a direct health risk if left untreated.
Symptoms that typically qualify a hernia for surgical repair include persistent pain, functional impairment, or signs of incarceration or strangulation. Strangulation is a serious complication where the blood supply to the trapped tissue is cut off, which is a medical emergency requiring immediate surgical attention. The treating physician is responsible for documenting these specific symptoms and the rationale for the surgery to support the necessity of the procedure for Medicare payment. If a procedure were purely elective without a documented medical need, Medicare would not provide coverage.
Financial Responsibility Under Medicare Parts A and B
Even when the procedure is deemed medically necessary, beneficiaries under Original Medicare (Parts A and B) are responsible for specific out-of-pocket costs. The financial responsibility depends on whether the repair is performed on an inpatient or outpatient basis, triggering the respective Part A or Part B cost-sharing rules. For the common outpatient hernia repair, the beneficiary must first satisfy the annual Medicare Part B deductible, which is \$257 in 2025.
Once the Part B deductible has been met, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for all Part B covered services. This 20% coinsurance applies to the surgeon’s fee, the facility charge for the outpatient surgery center, and any other Part B services related to the procedure. Since Original Medicare has no annual out-of-pocket maximum, this 20% share can accumulate depending on the total cost of the surgery and associated care.
If the hernia surgery requires an inpatient hospital stay, the Medicare Part A deductible applies, which is \$1,676 per benefit period in 2025. This deductible covers the entire hospital stay for the first 60 days. It is applied per benefit period, meaning a patient could potentially incur this cost more than once if readmitted after a 60-day break. Even in an inpatient setting, services like the physician’s fees and certain outpatient tests are still billed under Part B. Therefore, the 20% coinsurance and Part B deductible would also apply.
How Supplemental Plans Affect Coverage
Many Medicare beneficiaries enroll in supplemental coverage to help manage the out-of-pocket costs that remain after Original Medicare pays its share. The two primary types of supplemental coverage are Medicare Advantage (Part C) plans and Medigap (Medicare Supplement Insurance) policies. Medicare Advantage plans are offered by private insurance companies and must cover all the same services as Original Medicare, including medically necessary hernia surgery.
These Part C plans often have different cost-sharing structures, typically using fixed copayments for services like a specialist visit or a hospital stay, instead of the 20% coinsurance. A significant difference is that Medicare Advantage plans include an annual out-of-pocket spending limit, which provides a cap on the beneficiary’s yearly medical costs for Part A and B covered services. Medigap policies are specifically designed to pay for the “gaps” in Original Medicare coverage, such as the deductibles, copayments, and coinsurance amounts. Depending on the specific Medigap plan selected, it can cover the entire Part B 20% coinsurance and may also cover the Part A and Part B deductibles, substantially reducing the patient’s financial responsibility.