Medicare covers hernia repair surgery as an inpatient or outpatient procedure when your doctor says it is medically necessary, but what you pay depends on which type of Medicare you have and whether your surgeon operates in a hospital outpatient department or an ambulatory surgery center.

A small hernia — one that causes pain, keeps growing, or risks becoming trapped — is usually considered a condition that needs treatment rather than one you can watch. Medicare Part B covers the surgeon's fee and anesthesia for hernia repair. The facility where surgery happens (hospital outpatient department or surgery center) is covered separately. You will owe a copay or coinsurance, and the exact amount depends on your plan and where the procedure takes place.

If you have Original Medicare (Part A and Part B), you pay 20 percent of the approved amount for the surgeon and facility after you meet your Part B deductible. If you have a Medigap or Medicare Advantage plan, your out-of-pocket cost may be lower, but you need to check your specific plan documents or call your plan to know the exact amount.

Key Takeaways

  • Medicare Part B covers hernia repair surgery when your doctor documents that it is medically necessary, not cosmetic.
  • You pay 20 percent coinsurance for the surgeon and facility costs under Original Medicare after meeting your Part B deductible.
  • Outpatient surgery at a hospital or surgery center is covered the same way as inpatient surgery — the setting does not change coverage.
  • Your actual out-of-pocket cost depends on whether you have Original Medicare, Medigap, or Medicare Advantage, so call your plan before surgery to get a cost estimate.
  • Your surgeon's office should submit the claim to Medicare; you do not need to file anything yourself.

How Medicare decides whether hernia surgery is medically necessary

Medicare covers hernia repair when your doctor documents that the hernia is causing symptoms or poses a risk of complications. Symptoms include pain, swelling, or a bulge that worsens with activity. A hernia that is enlarging, cannot be pushed back in, or is at risk of becoming strangulated (cutting off blood supply) also meets the standard for coverage.

A small hernia that causes no symptoms and is not growing may not be covered, because Medicare considers it observation-appropriate rather than requiring surgery. Your surgeon will document the reason for surgery in your medical record, and that documentation is what Medicare uses to decide coverage. You do not need to do anything — your doctor's office handles this part.

What you pay under Original Medicare

Under Original Medicare, you pay 20 percent of the approved amount for both the surgeon and the facility (hospital outpatient department or ambulatory surgery center). You must first meet your Part B deductible for the year — in 2024 that is $240, though this amount changes yearly. Once you meet the deductible, you owe 20 percent of all approved charges for the rest of that calendar year.

The surgeon's office will bill Medicare directly. Medicare sends you an Explanation of Benefits (EOB) showing what they approved and what you owe. The facility (hospital or surgery center) also bills Medicare separately. You may receive two bills — one from the surgeon and one from the facility — or the facility may bill on behalf of the surgeon. Either way, you are responsible for 20 percent of each approved amount.

The actual dollar amount depends on what Medicare approves in your area and what the surgeon charges. A surgeon's office can give you an estimate based on the procedure code, but the final amount will not be clear until after surgery when Medicare processes the claim.

What you pay with Medigap or Medicare Advantage

If you have a Medigap (supplemental) plan, the plan pays some or all of your 20 percent coinsurance, depending on which Medigap plan you own. Plans C, D, F, and G cover the Part B coinsurance, meaning you may owe nothing out of pocket beyond your Part B deductible. Plans A, B, K, and L cover part of the coinsurance. Call your Medigap plan to confirm what hernia surgery will cost you.

If you have Medicare Advantage (Part C), your plan acts as your Medicare coverage. Most Medicare Advantage plans cover hernia repair, but your copay or coinsurance amount is set by your plan, not by Medicare. Some plans charge a copay per visit or procedure; others charge coinsurance (a percentage). Call your Medicare Advantage plan before scheduling surgery to learn your exact cost and whether your surgeon is in-network. Out-of-network surgery may cost more or may not be covered at all.

Outpatient versus inpatient surgery and what it means for your bill

Hernia repair is often done as outpatient surgery, meaning you go home the same day. Medicare covers outpatient hernia repair the same way it covers inpatient repair — you pay 20 percent coinsurance under Original Medicare. The setting (hospital outpatient department, ambulatory surgery center, or office-based surgery) does not change your coverage level.

However, the facility you choose may affect your actual cost. Hospital outpatient departments and ambulatory surgery centers bill differently, and Medicare may approve different amounts for the same procedure at different locations. A surgery center may have lower facility charges than a hospital, which could mean lower coinsurance for you. Ask your surgeon whether the procedure can be done at a surgery center and whether that would lower your out-of-pocket cost.

What to ask your doctor and surgeon before scheduling

Before you schedule hernia repair, ask your surgeon's office to provide a cost estimate. Give them your Medicare number and any supplemental or Advantage plan information. Ask them to tell you the procedure code (usually CPT code 49505 or 49507 for small hernias) and to estimate what Medicare will approve in your area. Ask whether the procedure will be done at a hospital outpatient department or a surgery center, because that affects the facility charge.

Ask your surgeon whether the hernia is small enough to be repaired without mesh or whether mesh will be used, because that can change the procedure code and the cost. Ask how long recovery takes and whether you will need follow-up visits, because those visits are also covered by Medicare and you will owe coinsurance for them too.

If you have Medigap or Medicare Advantage, call your plan directly and give them the procedure code. Ask what your coinsurance or copay will be and whether there are any limits on surgeon choice or facility choice. Do not rely on the surgeon's office estimate of your plan's cost — plans change their coverage, and your plan can tell you exactly what you owe.

When Medicare may not cover hernia repair

Medicare does not cover hernia repair if your doctor documents that it is cosmetic or elective with no medical reason. A very small hernia that causes no pain and is not growing may fall into this category. If your surgeon believes the hernia is cosmetic rather than medically necessary, Medicare will deny the claim, and you will owe the full cost.

Before surgery, ask your surgeon to confirm in writing that the hernia meets Medicare's standard for medical necessity. If there is any doubt, ask your surgeon to submit the case to Medicare for a coverage information before you schedule surgery. This takes a few weeks but can prevent a surprise bill if Medicare later decides the surgery was not covered.

Frequently Asked Questions

Do I need to get approval from Medicare before hernia surgery?

No. Your surgeon does not need to request pre-approval from Medicare for hernia repair. However, if your surgeon thinks there is any chance Medicare will consider the hernia cosmetic rather than medically necessary, you can ask your surgeon to submit a coverage information request before surgery. This takes two to three weeks but protects you if Medicare would otherwise deny the claim.

Will I owe anything if I have not met my Part B deductible yet this year?

Yes. You will owe your full Part B deductible (in 2024, $240) plus 20 percent of the approved charges for the surgeon and facility. Once you meet the deductible, you owe only 20 percent for the rest of the calendar year. If you have Medigap, your plan may cover the deductible depending on which plan you own.

What if my surgeon is out of network with my Medicare Advantage plan?

Most Medicare Advantage plans allow you to see any Medicare-participating provider, but you may pay more for out-of-network care. Some plans charge higher coinsurance or require you to pay the full bill upfront and then request reimbursement. Call your Medicare Advantage plan before scheduling to confirm whether your surgeon is in-network and what you will owe if you see an out-of-network surgeon.

Can I have hernia surgery at an office-based surgery center instead of a hospital?

Yes, if your surgeon offers it and it is safe for your hernia. Office-based surgery centers are covered by Medicare the same way as hospital outpatient departments and ambulatory surgery centers. The facility charge may be lower at an office-based center, which could reduce your coinsurance. Ask your surgeon whether this option is available and whether it would lower your cost.

What happens if I receive a bill after surgery that says Medicare denied it?

Contact your surgeon's office when ready and ask them to appeal. If Medicare denied the claim because it considered the hernia cosmetic, your surgeon can submit additional medical records showing why the repair was medically necessary. If the denial is a billing error, the surgeon's office can correct it and resubmit. Do not pay a bill for a denied claim without first asking your surgeon's office to appeal.