Does Medicaid Cover Surgery?

Medicare Benefits Solutions
Dec 7, 2020

Medicaid is an important program in the lives of millions of American families. It provides medical care benefits to adults in all 50 states, and while it is a federal program governed by the Centers for Medicare & Medicaid Services, it is administered on the state level. This means that benefits offered by Medicaid can differ from state to state, but most are similar when it comes to routine medical care and many advanced treatments.

Does Medicaid Cover Surgery?

Medicaid does cover surgery as long as the procedure is ordered by a Medicaid-approved physician and is deemed medically necessary. Additionally, the facility providing the surgery must be approved by Medicaid barring emergency surgery to preserve life. Aftercare for rehabilitation following surgery should be covered by Medicaid, and any prescriptions required to recover properly after surgery should also be covered.

As with Medicare benefits, the key to receiving covered surgery under Medicaid is the medical necessity of the procedure. Cosmetic surgery is not covered by Medicaid nor Medicare benefits, but reconstructive surgery may be covered as long as it is medically necessary to make a person whole again. Likewise, surgical procedures for weight loss, like liposuction, are not covered by either program, but bariatric surgery for weight loss pertaining to overall health should be covered.

Can I be Reimbursed for Surgery?

Because Medicaid requires that surgery be performed by approved care providers, Medicaid recipients often wonder whether they can seek care outside of the Medicaid network and then be reimbursed for care. In the vast majority of cases, this is not possible. All surgery that is covered by Medicaid must be performed by a surgeon who is a part of the Medicaid network. If you undergo surgery performed by a healthcare provider who does not participate in Medicaid, you can expect to pay out of your own pocket for the expense. No reimbursement will be offered.

Things to Improve the Odds of Approval

If you are in need of surgery and you’re a Medicaid recipient, there are a few things you can do to improve your odds of having your surgery approved. First, check out your state’s Medicaid directory to find participating surgeons in your area. These providers have already been approved by Medicaid and will offer the most efficient experience. Second, talk to your physician to see if alternatives exist to surgery in the event that your procedure is not approved. This will give you options to address your medical concerns until you can get the surgery situation resolved.

Finally, discuss aftercare options with your physician to ensure that any care, therapies, medical devices or medications required to recover will also be covered by Medicaid. This can also be beneficial information to know so that your surgical plan can be adjusted to meet your needs and abilities following the procedure.

Can You be Dual-eligible for Medicaid and Medicare?

Depending on your circumstances, you may also be eligible to receive benefits from both Medicaid and Medicare. Dual-eligibles must meet the minimum qualifications for both programs, but having benefits available from Medicaid as well as Medicare can help to provide a greater number of options when in need of surgery. Dual-eligibles may also be able to seek care from a wider number of providers, but you will need to consult with a directory of providers from each program to know your unique options.