Does Medicaid Cover Hysterectomy?
- Does Medicaid fund a hysterectomy? Discover how Medicaid and Medicare funding for hysterectomies works, including when a hysterectomy is medically necessary.
A hysterectomy is a surgery to remove the uterus. It's sometimes recommended to treat conditions such as uterine cancer and endometriosis. Hysterectomies are expensive out of pocket, so most people rely on their health insurance or a federal or state health care plan to fund their surgery.
Does Medicaid fund hysterectomy? Below, you can find out who qualifies for a hysterectomy through Medicaid and Medicare.
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Does Medicaid Cover Hysterectomy?
Medicaid almost always covers medically necessary emergency surgery, and it often funds elective surgery if there is a clear medical indication. Therefore, Medicaid will likely cover medically necessary hysterectomies for eligible beneficiaries, but specific limitations vary by state. You can check your state's coverage for hysterectomies by contacting its Medicaid Agency.
Hysterectomies are sometimes carried out for permanent sterilization. A hysterectomy is more invasive than other surgical sterilization techniques such as tubal ligation and carries a higher risk of serious bleeding. However, it guarantees that you cannot become pregnant and could reduce your chances of developing a uterine disease later on. Therefore, some surgeons may recommend a hysterectomy for sterilization if you are also at an increased risk of developing conditions like uterine cancer.
Medicaid is unlikely to cover a hysterectomy if the primary reason for the surgery is sterilization. This means that you can't usually have a hysterectomy through Medicaid if you want it done to prevent pregnancy. Many states also exclude hysterectomies from their Medicare coverage if they are proposed to treat a medical condition and as a sterilization method but the beneficiary's primary motivation to seek a hysterectomy is sterilization.
Usually, you'll need to complete a hysterectomy acknowledgment form before Medicaid funds your surgery. This form is a signed statement confirming that your doctor explained that having a hysterectomy will make you infertile. You may not need to complete a hysterectomy acknowledgment form if you were already sterile before the treatment or if it is necessary to treat a life-threatening health event where an emergency makes it impossible to obtain a written statement.
Does Medicare Cover Hysterectomy?
Medicare may cover the costs of a hysterectomy if it is medically necessary. For example, it may fund surgery if you need a hysterectomy to treat gynecologic cancer or a pelvic injury. If you're eligible, Medicare Part A covers the cost of your inpatient care minus the Part A deductible, which is $1,484 as of 2021. You may also be liable for coinsurance if you are hospitalized for more than 60 days.
Medicare Part B covers 80% of the Medicare-approved amount for outpatient care required before or after a hysterectomy for eligible beneficiaries. You may be required to make a copayment, and you're also responsible for paying the $203 annual Part B deductible.
Having a hysterectomy is a major decision because it will make you infertile and comes with certain risks, but it is often the best treatment option for certain conditions. In recognition of the gravity of this decision, Medicare often covers the costs of getting a second opinion before surgery if you want one.
Do Medicare Advantage Plans Cover Hysterectomy?
Medicare Advantage Plans are Medicare-approved plans available through private insurers. Providers must offer the same coverage as Original Medicare for Medicare Advantage beneficiaries. Therefore, you will be covered for a hysterectomy if you would have been eligible for funding through Original Medicare.
However, some Medicare Advantage Plans offer more comprehensive coverage than Original Medicare and may cover hysterectomies for a wider range of conditions. For example, your Medicare Advantage Plan may cover hysterectomies for benign conditions that would not meet the regular Medicare thresholds of medical necessity. You should check with your private insurer to find out when it covers hysterectomies and its eligibility requirements.
When Is a Hysterectomy Medically Necessary?
According to the National Women's Health Network, a hysterectomy is considered medically necessary to treat a life-threatening health condition. For example, it may be required to treat gynecologic cancer, unmanageable infection or bleeding or a childbirth complication such as uterine rupture.
It may be appropriate to try less invasive treatments before deciding to have a hysterectomy, but this may not be possible in an emergency. For example, there are various potential alternatives to treat non-life-threatening conditions sometimes treated with a hysterectomy, such as fibroids, endometriosis and uterine prolapse. It's a good idea to ask your doctor if it's worth trying any non-invasive alternatives before deciding to have a hysterectomy.
How Are Hysterectomies Performed?
There are three types of hysterectomy.
- Partial: Some or all of the uterus is removed, but the cervix is left in place.
- Total: The uterus and cervix are removed. Sometimes, one or both of the ovaries or Fallopian tubes are also removed during a total hysterectomy.
- Radical: The top of the vagina, cervix and uterus are removed. Sometimes, the ovaries and Fallopian tubes are also removed. A radical hysterectomy may be required to treat some cancers.
There are several methods for performing a hysterectomy, and your doctor will recommend a method based on your medical condition and history and the surgeon's experience.
An open hysterectomy usually involves removing the uterus through a horizontal incision along the bikini line, but a vertical incision is sometimes necessary. Open hysterectomies generally cause more post-operative pain and have a longer recovery time, so this method is generally only used if the uterus is enlarged or there is a clinical reason for opening the abdomen, such as to remove cancerous tissue.
Hysterectomy surgery is sometimes performed vaginally, where the uterus is removed from a small cut at the top of the vagina. Alternatively, the surgeon may perform a laparoscopy. During a laparoscopy, instruments are inserted through small abdominal incisions. The uterus can then be removed vaginally or in smaller pieces through the abdominal incisions. Vaginal and laparoscopic hysterectomies are less invasive than abdominal hysterectomies, so they generally cause less post-operative pain and allow for a quicker recovery.
How Do I Qualify for a Hysterectomy?
To qualify for a hysterectomy through Medicaid or Medicare, your doctor will need to provide evidence of your medical need for surgery. In some cases, you may be required to try less invasive treatment first to see if it improves your condition. However, this is less likely if your condition is life-threatening.
How Much Does It Cost to Have a Hysterectomy?
A hysterectomy generally costs somewhere between $10,000 and $20,000 out of pocket. The overall cost depends on several factors, including your overall health status, the surgical technique used and whether you need a partial, total or radical hysterectomy.