July 22, 2024

How Much of Your Surgery Will Health Insurance Cover?

The news that you need surgery is likely to cause anxiety right away: Will the operation be successful? How much suffering are you willing to put up with? How long will it take you to get back on your feet?

Cost worries are likely to follow closely behind. If you have health Life Insurance, you’ll want to know how much your plan will cover for the surgery.

The good news is that most health insurance plans cover a significant portion of surgical costs for procedures that are deemed medically necessary, such as surgery to save your life, improve your health, or prevent illness. This can range from an appendectomy to a heart bypass, but it can also include procedures like rhinoplasty (nose surgery) if the goal is to improve breathing.

Although most cosmetic surgery is not covered by insurance, certain procedures are usually considered medically necessary when performed in conjunction with other medical treatment. Breast implants, which are placed during or after breast cancer surgery, are an excellent example.

Coverage Differs by Insurer

Every health plan is unique. Your homework consists of two parts: talking to your healthcare provider and studying your health insurance plan to better understand the financial implications of your surgery.

Inquire with your surgeon about the cost of your procedure, as well as the preparation, care, and supplies that will be required.

It’s worth noting that hospitals and doctors aren’t always able to provide precise estimates because they don’t always know what they’ll face once the procedure begins. However, the more questions you ask, the more data you’ll gather.

Read the summary you got when you signed up for your plan. Insurance companies typically list covered and excluded costs for care in this booklet. If you don’t have this information, contact your health insurance provider.

Learn what your insurer requires in terms of prior authorization and/or a referral from your primary care physician. The specifics vary by plan, but you’ll almost certainly need one or both of these to be covered for your upcoming surgery.

Other Items Add to the Cost

Surgery has a financial cost that goes beyond the cost of a single procedure. Other expenses could include:

  1. Blood tests, X-rays, and MRIs are examples of pre-operative tests that help your doctor prepare for surgery and/or ensure your fitness for it.
  2. The use of an operating room or other surgical setting, which has a per-procedure or per-hour fee.
  3. Co-surgeons or surgical assistants (including nurses and/or doctors) who assist in the operating room (it’s critical to double-check that everyone involved in your surgery is covered by your insurance plan’s network).
  4. You may require plasma, blood, or other biological support to keep your condition steady.
  5. Intravenous medication, anesthesia, and/or the doctor(s) who will administer it are all required.
  6. The fee for the surgeon, which is usually distinct from the pay for the surgery itself (based on the situations, there might also be an associate surgeon who sends an additional bill)
  7. Medical equipment that is long-lasting (this includes things like crutches or braces that might be necessary after your surgery)
  8. The recovery room or area where you will be cared for after surgery.
  9. If you need inpatient care, your hospital stay.
  10. If you necessitate broad rehabilitative care post leaving the hospital but before you return at home, you will be charged by a skilled nursing facility.
  11. You may require part-time therapy or nursing care while recovering at home.

Each of these items may have different levels of coverage depending on your insurance. It’s a good idea to get a sense of what might be excluded.