Hernias do not improve without treatment and must usually be resolved with surgery.
If you have a bulge on your skin in the area on either side of your pubic bone, which becomes more noticeable when you’re upright, you might have a hernia. Some people are more aware of their hernias when they cough, bend over, or strain. Still others experience a burning or aching at the site of the bulge.
Do you think you have a hernia? Here’s what you need to know about hernias and Medicare coverage.
What is a hernia?
A hernia occurs when an organ pushes through one’s muscle wall. Typically, hernias happen in a person’s abdomen, but it’s possible to have a hernia in other places on the body. You might notice the telltale bulge under your skin where the hernia occurred, but some people with hernias have no symptoms.
There are several different types of hernias.
For example, inguinal hernias develop in the inner groin area. This type of hernia occurs when the intestine protrudes through either of two passages in the lower abdominal wall called inguinal canals. Femoral hernias develop in the upper thigh/outer groin area and are more likely to occur in women. They occur in deep passages called femoral canals.
Ventral hernias occur through an opening in the muscles of the abdomen. There are three types of ventral hernias:
**The epigastric hernia occurs above the belly button.
Incisional hernias are caused by muscle weakening caused by previous abdominal surgery.
Umbilical hernias are most common in newborns.**
Finally, hiatal hernias occur when the upper part of the stomach bulges into the chest through a small opening in the diaphragm.
Common causes of hernias
A combination of pressure and weak muscles often cause hernias. The pressure pushes an organ or tissue through an opening or weak spot. Sometimes muscle weakness is present at birth. But most of the time, it develops with age.
A hernia doesn’t go away on its own; it must be treated surgically. However, it's a fairly common procedure that's usually performed on an outpatient basis (which means Medicare Part B applies).
If your hernia is mild and doesn’t cause any pain, your doctor may recommend monitoring the situation and waiting to have surgery only if the hernia grows or becomes more painful. However, in some rare cases, people with hernias experience serious complications.
Medicare will cover the hernia surgery if your doctor deems it medically necessary.
Medicare and cost of hernia surgery
In most cases, hernia surgeries are performed in outpatient facilities, so you are unlikely to have to stay in a hospital following the procedure.
Medicare Part B
Medicare Part B (medical insurance) covers outpatient hernia procedures ordered by your physician.
Once your annual deductible is met ($226 in 2023), you can expect to pay 20% of the cost of the services. Medicare Part B covers the rest.
Let’s assume that your hernia surgery costs $5,000. If you have already met your yearly Medicare Part B deductible ($226), Medicare Part B will pay 80% of your surgery costs (in this case, $4,000). You would then be responsible for the remaining balance of $1,000 if you don't have a Medigap plan.
Medicare Part A
On the rare chance you end up requiring an inpatient hospital stay and are formally admitted, Medicare Part A (hospital insurance) applies. Once you pay the $1,600 deductible per benefit period (2023), you will pay $0 for the first 60 days of hospital services. You are also responsible for 20% of the Medicare-approved amount for doctor’s services you receive as an inpatient while in the hospital.
Remember: due to their excellent recovery and success rates, hernia surgeries do not often require hospital stays.
It’s also worth noting that your doctor may prescribe medications to help with post-surgery pain relief. A Medicare Part D prescription drug plan should cover any related prescription medications.
If you have Medicare Part C (more commonly known as Medicare Advantage), you have the same coverage as if you had Original Medicare – with a 99% chance you have extra benefits as well. And Part C has an annual max out-of-pocket (MOOP) that caps your spending at $8,300 for in-network care and $11,300 for in- and out-of-network combined.
Since Original Medicare has no yearly max, there's no limit to what you could owe in a year without a Medicare Supplement plan (Medigap). Our Find a Plan tool makes it easy to compare the costs of benefits of Medicare plans in your area. Just enter your zip code to get started.
Types of hernia surgery
There are three primary types of hernia surgeries: open hernia surgery, laparoscopic hernia surgery, and robotic hernia repair surgery.
During open hernia repair surgery, the surgeon creates an incision at the affected area – usually the groin – and identifies the "hernia sac" holding the bulging organ. They then push the hernia back into place and strengthen the abdominal wall, typically with a synthetic mesh, to reduce the chances of a future hernia. The area is then closed with stitches and the patient is advised to avoid strenuous activity for around four to six weeks.
The surgeon makes several small cuts in the lower abdomen during laparoscopic hernia surgery. Using specialized equipment, the surgeon views and repairs the hernia and places a piece of mesh inside to strengthen the abdominal wall. The tiny incisions required for laparoscopic surgery mean you experience less pain and a much quicker recovery time, a matter of days instead of a month or more.
Robotic hernia repair is similar to laparoscopic surgery except that it offers the surgeon a three-dimensional view of the area, making it even easier for the surgeon to complete the procedure. The patient also enjoys a speedier recovery time with a robotic surgery.
Recovery from hernia surgery
Even though hernia surgery is performed as an outpatient procedure, you will still have to go through a significant recovery process. If you had laparoscopic surgery, you might be able to return to normal activities within two weeks. However, you should avoid heavy lifting and strenuous activities for over a month.