Does Medicare Cover a C-Section? 

A C-section, also known as a cesarean delivery, is the term used for the surgical delivery of a baby. Obstetricians perform C-sections for a number of reasons, including when vaginal deliveries are too difficult or unsafe, or if the life of the mother or child is at risk. 

You might need a cesarean delivery if have a certain medical condition or you experience complications during labor, such as: 

• Disproportionate size of the baby’s head or body 
• A small pelvis
• Having had a previous C-section
• Multiple babies in one birth
• Position of placental attachment
• Abnormal position of the baby
• Heart disease 
• Genital herpes
• Difficult or prolonged labor
• The umbilical cord is wrapped around the baby’s neck or body, or it’s protruding from the cervix 
• The placenta separates from the wall of the uterus
• Fetal distress

Over the past 20 years, C-sections have become more common in the United States, and they now account for around 30 percent of all deliveries, according to the U.S. Centers for Disease Control and Prevention. 

If you’re enrolled in Medicare, and your obstetrician recommends that you undergo a C-section, you might need to know how your insurance will cover it. 

Does Medicare cover C-sections? 

While Medicare is typically known as health care insurance for people over the age of 65, it also covers people who are younger than 65 if they have a qualifying disability or certain medical conditions like end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS). For instance, if you receive Social Security benefits for 24 months due to a disability, you may be eligible for Medicare coverage regardless of your age. 

Therefore, if you qualify for Medicare and are enrolled in either Original Medicare or a Medicare Advantage (Part C) plan, you should have coverage for your C-section. 

C-section deliveries take place in a hospital because they are surgical procedures that require anesthesia and a short recovery period. Because you’ll be admitted as an inpatient, Medicare Part A covers these types of procedures. To be eligible for this benefit, your physician or obstetrician (who accepts Medicare assignment) must certify that the procedure is medically necessary, and must admit you to a hospital that also accepts Medicare. 

Original Medicare Part A covers the following services while you’re in the hospital: 

• C-section surgery 
• A semi-private room
• Meals
• General nursing care
• Prescription drugs you take during inpatient care

Part A doesn’t coverprivate nursing care, a private room that isn’t medically necessary, telephone or television rental fees, or other personal care items. 

It’s also important to note that your Medicare insurance plan doesn’t cover your baby or its care after it’s born. There are separate programs that may help you cover the medical care of your infant if you qualify.

What are your costs with Medicare?

Medicare Part A pays its share of your covered medical expenses after you pay your Part A deductible for the current benefit period. If your inpatient hospital stay doesn’t exceed 60 days, you won’t be charged a coinsurance payment. 

Original Medicare Part B covers your care before and after your C-section outside the hospital, your physician’s and surgeon’s fees for your care in and out of the hospital, and any additional (covered) medical services that are related to your C-section procedure and care. 

Medicare Part B pays 80 percent of the final approved amount for these medical services, and you pay 20 percent after meeting your annual deductible. 

How does a Medicare Advantage plan cover the costs of a C-section?

If you have a Medicare Advantage (MA) plan, your private insurance provider must cover all benefits included in Original Medicare Parts A and B. Most MA plans also offer extra benefits and additional coverage, so you may be entitled to more benefits. 

Depending on the type of Medicare Advantage plan you’re enrolled in, you may need to use specific doctors and hospitals that are plan-approved to be eligible for coverage. Also, the amount of your copayment and coinsurance charges may vary according to your plan.

If you’re enrolled in a Medicare Advantage plan, make sure you’re aware of any provider network requirements and fees before making health care appointments. If you need clarification, call your provider for assistance.