If you struggle with acid reflux, your doctor may decide to test you for gastroesophageal reflux disease (GERD). If you have GERD, there are some non-invasive treatments you can start with, including over-the-counter medicines, prescription medicines, and changes in your diet.
If the medications don’t work, however, or you are at risk of side effects, your doctor may recommend GERD surgery. If you have insurance coverage through Medicare, your first question might be “Is GERD surgery covered by Medicare?”
This guide will help you understand what to expect if you use your Medicare coverage for GERD surgery. Here’s what you need to know.
Original Medicare covers medically necessary surgery as long as the procedure is documented to be effective and you use a Medicare-enrolled provider. If you plan to pursue a newer treatment option, be sure to check with Medicare directly to find out if it has proper evidence of effectiveness.
Your doctor may not know if a specific procedure is approved by Medicare, and sometimes doctors do prescribe therapies or treatments that are not covered. That’s why it’s important to talk to Medicare directly.
If you have a Medicare Advantage plan, there are likely to be different copayment or coinsurance amounts for inpatient and outpatient surgery, as well. You’ll also want to make sure your doctors are within the insurance network.
Under Original Medicare, the amount you will pay depends on whether the surgery is covered under Part A (inpatient) or Part B (outpatient).
Many GERD surgeries are outpatient procedures. In this case, you’ll be responsible for your Part B deductible if it hasn’t been paid yet, and then you’ll pay 20% of the remaining Medicare-approved amount while Medicare pays the rest.
For an inpatient procedure, you’ll be responsible for your Part A deductible if it hasn’t been paid yet. After that, you’ll have a $0 coinsurance for days 1 - 60 of inpatient care in a year. Most inpatient GERD surgeries only require a few days in the hospital.
What if you don’t have Original Medicare, but you have a Medicare Advantage plan? In that case, you’ll pay a deductible and copayment or coinsurance depending on your plan. You’ll want to talk to the insurer to find out the details. Many times, for example, an Advantage plan will have a single flat copayment for outpatient surgery, rather than you paying a percentage.
One of the benefits of Medicare Advantage can be that the flat copayment amounts are more predictable than paying a percentage of costs. Because of that, many Americans find that an Advantage plan is a good choice for their needs.
Struggling with GERD is painful and can cause long-term damage, so if medication isn’t controlling it properly, you might need surgery. If your doctor finds that surgery is medically necessary and suggests a proven procedure, Medicare can help you pay for it.
If you have more questions about Medicare coverage or would like help comparing insurance plans to find the right one for you, we’re here to help. Simply contact us today to talk to a licensed agent!
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