Medicare / Medicaid and Cosmetic Plastic Surgery
This guide answers some of the frequently asked questions about Medicare and Medicaid issues regarding plastic and cosmetic surgery.
Does Medicare cover cosmetic surgery?
The general rule is that Medicare will not provide any funding for procedures or treatments which are for cosmetic purposes only. This includes treatments such as anti-wrinkle injections, microdermabrasion and liposuction. Cosmetic surgery is not deemed necessary and is therefore not covered by Medicare Part A, Medicare Part B nor a Medicare Part C Advantage plan. This is the same with most private cosmetic surgery health insurance plans.
Does Medicare cover plastic surgery?
Medicare may pay some costs towards plastic surgery, depending on the purpose of the operation. If the surgery is for cosmetic enhancement (such as breast enlargement or a face lift) then these are classed as ‘cosmetic surgery’ and are not covered. If on the other hand, the procedure is deemed ‘medically necessary’ (such as reconstructive surgery) then Medicare may pay a portion of your surgery costs.
When does Medicare deem procedures to be Medically Necessary?
There are three situations which Medicare considers necessary enough to warrant coverage. These are:
· To repair the body or a part following accidental injury (aging and weight gain is not accidental injury);
· To improve the function (not just the look) of a malformed part of the body (one which never developed or formed properly); or
· Breast reconstruction following a mastectomy due to breast cancer.
Who decides if the procedure is covered by Medicare?
You must first be examined by a licensed physician or other authorized medical provider. Once your condition has been assessed, the doctor must order or prescribe the treatment or procedure. However, just because the care is ordered or prescribed by an MD does not make it ‘medically necessary’. Medicare must agree that the care is necessary and proper. They have the final say on whether your treatment is covered. Unfortunately, in many cases the patient won’t know if Medicare will provide any funding until after the procedure. If you are relying on Medicare funding, make sure you have the treatment performed by a healthcare provider who participates in Medicare.
How Much Does Medicare Pay?
The portion paid by Medicare depends on how you receive the treatment. If you are admitted to hospital, then you are required to pay the deductible under Medicare Part A. If the reconstructive surgery is covered by Medicare then Medicare pays the full amount of covered inpatient hospitalization charges up to the allowed period (60 days). If the operation is performed at the doctor’s facility (whether inpatient or outpatient basis), Medicare Part B pays 80% of the amount approved by Medicare for such services. If the procedure is performed in the hospital outpatient department, then Medicare will cover all approved costs. You will be required to co-pay amounts above the Medicare-approved amount.
The purpose of Medicaid is to fund health care for US citizens and lawfully admitted immigrants who cannot afford to pay for their medical bills. The system sets down ‘eligibility groups’. The definitions are quite strict as to who is eligible and which procedures comply, in many cases cosmetic surgery is not covered. A cosmetic procedure may be covered by Medicaid (like in the Medicare system) if it’s necessary to restore function or alleviate pain. Some services require a co-payment.
The eligibility criteria are set down by each state and these must be met in addition to having a low income. For example, the criteria may consider your age and whether you are a child, pregnant, disabled or blind. It also takes into account your assets and resources. If you are medically needy and don’t pass the income and assets test, you may still be eligible if you have excessive medical expenses. Having a plastic surgery merely for cosmetic purposes does not class you as ‘medically needy’. The system does not cover cosmetic procedures because they are not necessary.
Cosmetic and plastic surgery is rarely covered under the Medicare and Medicaid schemes. Before you consider any procedure for which you require funding, be sure to speak with your doctor, surgeon and a Medicare/Medicaid representative first. If the procedure is not covered, you may need to consider cosmetic/plastic surgery financing. In some cases, taking a loan for the procedure is the only option where inadequate funds are a concern.