In the United States, hundreds of thousands of older adults have spine procedures each year. This number has been on the rise
in recent years, some research shows. The majority of this age group
receives their health insurance benefits through the Medicare program. For the most part, this insurance works well for older adults.
Dr. Khawar Siddique
, a neurospine surgeon at DOCS Spine + Orthopedics in Los Angeles, says, “Patients and doctors love Medicare over other commercial insurance policies because it is significantly easier to get approval for surgeries and the pre-certification process is much easier for Medicare.”
Traditional Medicare doesn’t require pre-certification — also know as prior authorization — for most of its services, except in a limited number of cases
However, Medicare Advantage plans can require people to get approval from the insurance company before receiving a service, and if approval is not given, then the plan generally does not cover the cost of the procedure. Some insurers may also require patients to consult with a rehabilitation specialist
about treatment options before non-emergency surgery.
These steps are done to keep patients from having unnecessary care, but it can add another hurdle for patients to get over. The ease of pre-certification depends on several factors, including the type of insurance that you have and the procedure.
There are a few other things you should know about Medicare and back surgery, both in terms of where you can have the surgery done and how much you will have to pay out of pocket.
Medicare coverage for back surgery
In general, the original Medicare program (Part A and Part B) will typically cover back surgery if your doctor deems it medically necessary. Medicare Advantage plans (Part C) also cover medically necessary back surgery.
“Medicare covers almost all spine surgery procedures, with few exceptions,” says Siddique. “One such exception is multi-level artificial disk replacements, but that is not covered by other commercial insurances either.”
Spine surgeries covered by Medicare — if they are deemed medically necessary — typically include:
- spinal laminectomy/spinal decompression
- spinal fusion
- single-level artificial disc replacement
Medicare Part A
covers inpatient hospital care. In order for your care to be covered, the following must be true:
- You must be admitted to the hospital on a doctor’s order, which says inpatient hospital care is needed to treat your back condition or injury.
- The hospital must accept Medicare.
- The hospital’s Utilization Review Committee approves your stay in the hospital (only in certain cases).
Medicare inpatient hospital care covers the following:
- Semi-private room (a private room is covered only if medically necessary)
- General nursing
- Medications required as part of your inpatient care
- Other hospital services and supplies
Medicare Part B
covers the cost of your doctor’s services while you are in the hospital and outpatient services after you are released from the hospital. This includes imaging, laboratory testing, and medical supplies related to your surgery or recovery. It also includes back surgery done at an ambulatory surgical center.
Dr. Richard Menger
, the chief of complex spine surgery at USA Health in Mobile, Alabama, cautions, “It is essential to recognize that the surgeon's fee is just one portion of the care delivery for spinal problems.”
(Part C) is private insurance that offers at least the same coverage as Original Medicare, although some services may only be covered in certain situations.
is available that may affect the cost of your surgery or related services, including Medicare Supplement Insurance
(Medigap) and Medicare Part D
(prescription drug). Medicare Advantage plans typically cover the cost of medications.
Cost of back surgery with Medicare
In general, having back surgery done at an outpatient facility will be cheaper than at a hospital. But Medicare doesn’t always cover outpatient surgeries.
“The problem is that Medicare typically favors inpatient hospitals over outpatient surgery centers when a patient needs surgery,” says Siddique. “Because of this, surgeons are sometimes forced to take the patient to a hospital rather than a surgery center.”
Some outpatient centers — also known as ambulatory care centers — have had issues with poor quality of care
. That’s why centers that provide care to Medicare patients need to be certified
by the U.S. Centers for Medicare & Medicaid Services (CMS).
Siddique adds that each year Medicare approves additional surgeries for its outpatient coverage list. He suggests that you check with your surgeon to see whether the procedure is approved for an outpatient facility. At the same time, it is a good idea to confirm that the center is certified by CMS.
Also, when it comes to your recovery plan, there are no guarantees. Menger says the surgeon, patient, physical therapy team, rehabilitation facility representative, and the insurance company all have to agree about whether post-surgical recovery will occur at a rehabilitation facility, skilled nursing facility, or with home health care.
“It's not automatic that if the patient wants to go to rehab, that they will be able to do so,” says Menger. “As a surgeon, this can be frustrating because even if I think it's the best care for my patient it might not happen.”
In terms of the cost of back surgery, it is difficult to determine the exact price beforehand because the services that you will need can change. For example, if your post-surgery recovery is slower than expected, you might need to stay longer in the hospital.
- Ask your doctor, hospital, or outpatient facility how much they think your surgery and follow-up care will cost you.
- If you have other insurance, check with your insurer to see what they will pay. This may include Medicare Supplement Insurance, Medicaid (for people with low incomes), or insurance from your or your spouse’s employer.
- Check your Medicare account (MyMedicare.gov) to see if you have met the deductibles for Part A and Part B.
A deductible is the amount you have to pay out of pocket for care before your insurance starts to pay. This typically resets to zero at the beginning of the year. Medicare deductibles
in 2020 were:
- Part A deductible: $1,408
- Part B deductible: $198
You may also be required to pay a portion of medical costs for your surgery and follow-up care, even after you meet your deductible. This is known as co-insurance. For Medicare plans, these are
- Part A co-insurance: $0 for days 1-60 of your benefit period. It increases after that. The benefit period starts when you are admitted to a hospital and ends when you have not required inpatient care for 60 consecutive days.
- Part B co-insurance: 20 percent of the Medicare-approved amount for the medical services or supplies.
Medicare Advantage plans may also have a yearly deductible and coinsurance.
Whatever the final bill ends up being, Medicare rates are set by CMS. However, you should check beforehand that your doctor, hospital, or outpatient center has accepted the Medicare “assignment
” for your surgery. Otherwise, they could charge you more than the Medicare rates.
“If your doctor or surgical facility accepts Medicare, it is illegal for them to charge you a penny more than what Medicare says is allowable,” says Siddique. “They cannot give you a discount to use their facility.”
If your doctor decides that back surgery is medically necessary for you, it will usually be covered by Original Medicare (Part A and Part B), as well as by Medicare Advantage. You should always confirm with your doctor, hospital, or surgical center that they will charge you the Medicare rates.
Even though you have Medicare, you will likely have to pay some of the costs out-of-pocket. The only exception is if you have met your yearly deductible and your plan doesn’t require you to pay co-insurance for your procedure or recovery. Determining how much is difficult because the exact services you will require is unknown. Your doctor and hospital or outpatient facility should be able to provide you with an estimate of your costs for the surgery.
Updated: August 6, 2020