Will Health Insurance Pay for Elective Surgery?

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Think health insurance won’t pay for elective surgery? Wrong. Health insurance will pay for elective surgery. In fact, the majority of surgical procedures done in the United States are elective surgeries; most are paid for, at least in part, by health insurance. Even Medicare and Medicaid pay for elective surgery.

The catch is that most health plans will only pay for elective surgery that’s medically necessary, and your health insurer’s opinion of what’s medically necessary may differ from your surgeon’s opinion.

Why The Elective Surgery Coverage Issue Confuses People

People think that health insurance won’t pay for elective surgery because they confuse the term “elective” with the term “not medically necessary.” They’re not the same thing.

An elective surgery is a surgical procedure you may choose to have, or choose (elect) not to have. Some elective surgeries are medically necessary; some are not.

Each health plan will have a slightly different definition of medically necessary. However, in general, a medically necessary surgical procedure:

  • Treats or diagnoses an illness, injury, deformity, disease, or significant symptoms such as severe pain.
  • May be required for your body to function the way it’s supposed to function, or as close to that as possible.

Examples of Elective Surgery & Medically Necessary Surgery

  • Elective & Medically Necessary. You have severe knee arthritis. You’ve tried treatments like joint injections, non-steroidal anti-inflammatory drugs, and even lost some weight. You have difficulty getting up and down your front porch stairs. Your orthopedic surgeon says you need a knee replacement. You schedule the surgery for next September because your grandchildren are coming to visit over the summer and you don’t want to be recovering during their visit.

    The surgery is medically necessary because you need it to allow your knee to function as closely as possible to the way it’s supposed to function. The surgery is elective because you can choose to delay it until September, choose to have it next week, or choose to forgo it altogether and just hobble around and be in pain. Most health plans would cover this surgery.
  • Non-Elective & Medically Necessary. You’re shot in the neck in a hunting accident. You’re losing a large amount of blood and you’re having trouble maintaining your airway. You’re taken by helicopter to the trauma center where you’re quickly taken to surgery.

    This emergency surgery was not elective. If you had chosen to forgo the surgery, you would have died—quickly. The surgery could not have been postponed. In fact, you were lucky to have even made it to the operating room alive. The surgery was medically necessary to control the bleeding, protect your airway, and repair the damage cause by the gunshot wound. Most health plans would cover this surgery, although, depending on the circumstances of the accident, there may also be some question of the shooter’s liability.
  • Elective But Not Medically Necessary. You’re seeing signs of aging and don’t feel good about the way you look. You’ve tried Botox and dermal fillers, but you feel like you could look better. The plastic surgeon suggests that a full facelift is the only procedure likely to produce the effect you desire. You schedule it for next month.

    The facelift is not medically necessary because your face functions just fine. You can close and open your eyelids correctly, get food into your mouth, and keep it there. The facelift is elective because you can choose to have it or choose not to have it. Most health plans would deny this surgery. You’re likely to have to pay for it yourself.

Most health plans will cover elective surgery that’s medically necessary as long as you follow the health plan’s medical management rules. If your health plan requires prior authorization, get it. If your health plan requires you use an in-network provider, do so. If your health plan does not agree that your surgery is medically necessary, it’s unlikely to pay for it.

Even when a health plan covers an elective surgery, it rarely pays 100% of the cost. An elective surgical procedure would be subject to the health plan’s cost-sharing arrangements, so you may have to pay a deductible or coinsurance.

Gray Areas

Sometimes a health plan may cover elective surgery even though it’s not technically medically necessary. For example, most health insurance covers breast reconstruction or breast implant surgery following a mastectomy for breast cancer. Many health plans cover sterilization surgeries like tubal ligation and vasectomy.

Sometimes you may think a procedure is medically necessary, but your health insurance company’s medical necessity reviewer disagrees. In these cases, you have the right to appeal that decision. Learn more in “Why Does Your Health Plan Say the Care You Need Isn’t Necessary?

Now that you know health insurance pays for elective surgery, see what other misconceptions you have about health insurance. Top 7 Health Insurance Myths

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