Original Medicare, and some Medicare Advantage plans, cover hernia surgery when it is medically necessary. Similar to other types of surgery, different parts of Medicare may cover certain aspects of care.
The care related to hernia surgery may vary depending on the procedure, the surgical setting, and any complications that develop.
This article describes hernias and hernia surgery, and looks at Medicare coverage, costs, and possible financial assistance.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
A hernia involves a weakness in the muscular tissue that holds an organ in place. The weakness causes the organ to bulge, which creates a lump under the skin. In many cases, a hernia involves the abdominal wall.
Causes
Activities and factors that place pressure on the abdominal wall, and therefore increase a person’s risk of a hernia, may include:
- chronic straining, such as coughing and constipation
- strenuous activities that cause straining, such as weightlifting
- pregnancy
- being overweight
- cystic fibrosis
- enlarged prostate
- peritoneal dialysis
- poor nutrition
- smoking
Types of hernia
There are several types of hernia, with the most common being an inguinal hernia, which involves the lower abdominal wall in the groin area. It is more common in men than in women.
Other types of hernia include:
- Incisional hernia: A person who had abdominal surgery may get this type of hernia.
- Femoral hernia: This bulge can appear in the upper part of a person’s thigh, and is less common in men.
- Hiatal hernia: This hernia is seen in the upper part of the stomach.
- Umbilical hernia: If the muscle around a person’s belly button does not close after birth, it can result in this type of hernia.
Symptoms
Some people may not have hernia symptoms, and the bulge may be painless and only appears when a person coughs or strains. However, where there are hernia symptoms, they may include:
- increased pain at the lump
- pain when lifting
- increase in the size of the bulge
- aching at the bulge
Hernia surgery involves repairing the weakness in the muscular tissue. The procedure may depend on the type and size of the hernia.
The two main procedures for hernia surgery include open surgery and laparoscopic repair.
During an open hernia surgery, the surgeon makes a cut over the hernia and places the protruding organ back in place. The surgeon may also put mesh in the abdominal wall to strengthen the area and then close the cut with surgical glue, staples, or stitches.
A laparoscopic repair surgery, also known as keyhole surgery, is done under general anesthesia. It involves making a small cut in the abdomen, with a camera and light inserted via a thin tube through one of the small cuts to view the abdomen. The surgeon repairs the hernia with surgical instruments inserted through another small cut. During the operation, the abdomen is inflated with gas to enable the surgeon to have the best view of their work area.
Medicare is a federal program, and it has four parts, including original Medicare (Part A and Part B), Part C, and Part D. Various parts provide coverage for surgery, as follows.
Medicare Part A
Hernia repair surgery may be done in an outpatient surgical center. However, if a person has surgery as a hospital inpatient, Medicare Part A covers the cost of inpatient hospital services and stays.
For inpatient hernia surgery, the coverage includes:
- anesthesia used while inpatient
- nursing care
- semi-private room
- meals
Medicare Part B
Medicare Part B covers outpatient hernia surgery. The services covered by Part B for hernia surgery include:
- doctor’s fee
- facility services
- prescription medications for post-hernia surgery pain control
- anesthesia
Part B also covers a second opinion by another doctor, as long as the surgery is not an emergency. Medicare also pays for a third opinion if the first and second opinions differ.
A person can use this online tool to get more information about hernia surgery as an outpatient.
Part C
Medicare Part C is also known as Medicare Advantage, and is an alternative to original Medicare (parts A and B). Advantage plans must provide at least the same medical and hospital benefits as original Medicare. An Advantage plan covers hernia surgery.
Part D
Medicare Part D is optional prescription drug coverage for a person enrolled in Medicare. It covers prescription drugs for hernia surgery recovery, such as pain medication.
The costs of hernia surgery may vary depending on several factors, such as whether the surgery is done on an outpatient or inpatient basis. The type of procedure may also be a factor in costs.
However, it is difficult to determine the exact costs of hernia surgery before the procedure because the total care and services are unknown.
According to a Medicare online tool, repair of a recurrent inguinal hernia, done at any age, varies between $407–$753, as shown in the table below.
The costs shown are averages across the nation, based on Medicare’s payments and copays in 2019.
| Doctor’s fee | Facility’s fee | Total cost | Medicare pays | A person pays | |
|---|---|---|---|---|---|
| Ambulatory centers for surgery | $664 | $1,377 | $2,041 | $1,632 | $407 |
| Hospital outpatient department | $664 | $3,109 | $3,733 | $3,018 | $753 |
There are several programs that may help with costs, such as Medicaid, Medigap, and Medicare savings programs (MSPs) including the Qualified Medicare Beneficiary (QMB) program.
- Medicaid helps a person who has limited income and resources, and may help cover certain expenses related to hernia surgery. Coverage varies among states.
- Medigap is supplemental insurance used to pay out-of-pocket costs such as deductibles and copays. It is offered by private health insurance companies, and coverage and costs vary between plans.
- The QMB program pays Medicare Part A and Part B premiums, along with copays, coinsurance, and deductibles. It may also help with prescription drug costs and is based on a person’s income and resources.
Medicare offers coverage for hernia surgery, with Part B covering 80% of the costs. A person with a Medicare Part C (Medicare Advantage) plan may also have coverage. There are several programs that can offer additional financial assistance, including to a person with limited income and resources.