Medicare copay for UroLift depends on whether you have it in a hospital outpatient department or an ambulatory surgery center

If you have Original Medicare (Parts A and B), you do not pay a copay for UroLift. Instead, you pay a coinsurance — a percentage of the cost after Medicare pays its share. In a hospital outpatient setting, you typically pay 20% of the Medicare-approved amount after you meet your Part B deductible. In an ambulatory surgery center, the cost structure is the same: 20% coinsurance after your deductible.

If you have a Medicare Advantage plan (Part C), your copay or coinsurance depends entirely on your specific plan. Some plans charge a flat copay for outpatient surgery (often $250 to $500), while others charge coinsurance. You need to check your plan documents or call your plan's customer service line to find your exact cost.

The total amount you owe also depends on whether you have already met your Part B deductible for the year. For 2024, the Part B deductible is $240. Once you meet it, you pay only the coinsurance percentage for the rest of the year.

Key Takeaways

  • Original Medicare charges 20% coinsurance for UroLift after you meet your $240 Part B deductible, not a fixed copay.
  • The actual dollar amount you pay depends on the Medicare-approved charge at your specific facility, which varies by location and facility type.
  • Medicare Advantage plans set their own copays or coinsurance amounts, so you must contact your plan directly to learn your cost.
  • You should ask your urologist's office to tell you the Medicare-approved charge before your procedure so you can estimate your out-of-pocket cost.

How to find out your exact copay or coinsurance before the procedure

Call your urologist's billing department and ask for the Medicare-approved charge (also called the allowed amount) for a UroLift procedure at their facility. This is the dollar figure Medicare uses to calculate your coinsurance. Multiply that number by 0.20 to estimate your 20% coinsurance cost — but only if you have already met your Part B deductible.

If you have not met your deductible yet, you will owe the full deductible amount first, then 20% of the remaining charge. The billing staff can tell you whether your deductible has been met by checking your Medicare account.

If you have a Medicare Advantage plan, call your plan's customer service number (on the back of your insurance card) and ask what you will pay for an outpatient UroLift procedure. Have the facility name and location ready, because some plans charge different amounts depending on whether the procedure is done in a hospital or surgery center.

What Medicare covers for UroLift

Medicare covers UroLift as a treatment for benign prostatic hyperplasia (BPH) — enlarged prostate that causes urinary symptoms. The procedure itself, the surgeon's fee, anesthesia, and facility costs are all covered under Part B when performed by a Medicare-enrolled provider.

What Medicare does not cover includes any charges from out-of-network providers (if you use a Medicare Advantage plan with network restrictions) and any facility upgrades you choose, such as a private recovery room. Your urologist should tell you upfront if any part of the procedure or facility is not covered by Medicare.

The difference between Original Medicare and Medicare Advantage costs

Original Medicare is predictable: you always pay 20% coinsurance after your deductible, no matter where you have the procedure done. Medicare Advantage plans vary widely. Some charge a copay that does not count toward your out-of-pocket maximum, while others charge coinsurance that does. Some plans require prior authorization from the insurance company before the procedure, which can delay scheduling.

If you are considering switching plans or are newly enrolled, ask whether your plan covers UroLift at your preferred urologist's facility. Some Medicare Advantage plans do not contract with certain surgery centers, which means you would pay more or have to travel to an in-network facility.

What happens if you have both Medicare and another insurance

If you have Original Medicare and a Medigap policy, your Medigap plan may cover some or all of your 20% coinsurance, depending on which Medigap plan you have. Plans C, D, G, and M cover the Part B coinsurance, so you would owe little or nothing out of pocket. Plans A, B, K, and L cover only part of the coinsurance. Call your Medigap insurer to confirm what they will pay for your UroLift procedure.

If you have Original Medicare and a retiree health plan from a former employer, that plan may also help cover your coinsurance. Contact your employer's benefits office or the plan directly to ask what they cover for outpatient surgery.

Costs you might not expect

Pre-procedure testing — such as urinalysis, blood work, or imaging — is usually covered by Medicare if ordered by your doctor. However, if your urologist orders tests that are not medically necessary for the procedure, Medicare may deny them, and you could be billed.

Post-procedure follow-up visits are covered by Medicare. If you need a catheter or other supplies after the procedure, ask whether they are covered or whether you need to purchase them separately. Some durable medical equipment suppliers bill Medicare directly; others ask you to pay upfront and submit a claim yourself.

Questions to ask your urologist before scheduling

Ask whether the facility is in-network for your Medicare Advantage plan (if you have one). Ask for the Medicare-approved charge and your estimated out-of-pocket cost. Ask whether prior authorization is needed and how long that takes. Ask what happens if complications arise and whether follow-up procedures would be covered at no additional cost or would require another copay or coinsurance payment.

Ask whether the facility bills Medicare directly or whether you will receive a bill and have to submit it yourself. Ask what payment arrangements they offer if you cannot pay the full amount upfront. Some facilities offer payment plans with no interest.

Frequently Asked Questions

Will my copay be different if I have the procedure at a hospital versus a surgery center?

No. Both settings charge 20% coinsurance under Original Medicare. However, the Medicare-approved charge may differ between facilities, so your actual dollar cost could be higher or lower depending on where you have it done. Medicare Advantage plans may charge different copays at different facility types, so check your plan documents.

Do I have to pay the full copay upfront, or can I pay after?

Most facilities ask you to pay your estimated coinsurance before the procedure. If you cannot pay the full amount, tell the billing department — many offer payment plans. You will receive an explanation of benefits (EOB) from Medicare after the procedure showing what was actually paid and what you owe.

What if Medicare denies the UroLift procedure?

If Medicare denies coverage, you would owe the full cost unless your urologist had you sign an advance beneficiary notice (ABN) before the procedure. An ABN tells you upfront that Medicare may not cover it and asks whether you want to proceed anyway and pay out of pocket. If you did not sign an ABN and Medicare denies it, you can appeal.

Can I use my Health Savings Account (HSA) or Flexible Spending Account (FSA) to pay my copay?

Yes. If you have an HSA or FSA, you can use those funds to pay your coinsurance and deductible. Keep your explanation of benefits and receipts for your tax records.

Will my copay count toward my out-of-pocket maximum?

Under Original Medicare, there is no out-of-pocket maximum — you pay coinsurance for every service. Under Medicare Advantage, coinsurance usually counts toward your out-of-pocket maximum, but copays may not. Check your plan documents or call your plan to confirm.