How Much of Your Surgery Will Health Insurance Cover?

The news that you need surgery is likely to elicit immediate worries: Will the operation work? How much pain will I endure? How long will it take to recover?

Concerns about costs are likely to follow close behind. If you have health insurance, you'll want to know how much of the surgery you can expect your plan to cover.

This article will explain what you need to understand about your health insurance policy, and the questions you need to ask to ensure that you aren't surprised by the bills you receive.

The good news is that most plans cover a major portion of surgical costs for procedures deemed medically necessary—that is, surgery to save your life, improve your health, or avert possible illness. This can run the gamut from an appendectomy to a hip replacement to a heart bypass, but it may also include procedures such as rhinoplasty (a nose job) if it's to correct a breathing problem.

Although most cosmetic surgery is not covered by insurance, certain operations are typically deemed medically necessary when they're done in conjunction with other medical treatments. A prime example is breast implants done as part of reconstruction after breast cancer surgery.

Coverage Varies by Insurer

Each health plan is different. To best educate yourself about the financial ramifications of your surgery, your homework is two-pronged—talking to your healthcare provider and studying your health insurance plan.

Ask your surgeon for a breakdown of what your procedure normally costs and what preparation, care, and supplies will be necessary.

Note that hospitals and healthcare providers sometimes can't provide accurate estimates, because they don't necessarily know what they'll encounter after they begin the procedure. But the more questions you ask, the more information you'll have.

Read the Summary of Benefits and Coverage that you received when you enrolled in your plan. Inside this booklet, insurance companies typically list covered and excluded costs for care. Contact your health insurance company if you do not have this information.

Find out what is required by your insurers in terms of prior authorization and/or a referral from your primary care provider. The specifics vary from one plan to another, but you'll likely need one or both of those in order to have coverage for your upcoming surgery.

You'll also want to understand how your cost-sharing is going to work, to get an idea of roughly what you can expect to pay when all is said and done. You'll need to know how much your deductible is, as the deductible is applicable to most surgical procedures. And after the deductible is met, most health plans have coinsurance (a percentage of the bill) that you'll have to pay until if and when you meet your plan's out-of-pocket maximum.

Other Items Add to the Cost

The financial toll of surgery extends beyond the cost of an individual procedure. Other costs can include:

• Pre-operative tests, such as blood work, X-rays, MRIs, etc., that help your healthcare provider prepare for surgery and/or ensure your fitness for it
• Use of the operating room or setting for the surgery, which has a per-hour or per-procedure cost
• Co-surgeons or surgical assistants, including healthcare providers and/or nurses, who help in the operating room
• Blood, plasma, or other biological support you may need to keep your condition stable
• Anesthesia, intravenous medication, and/or the healthcare provider(s) needed to provide it
• The surgeon's fee, which typically is separate from the fee for the actual surgery (depending on the circumstances, there may also be an assistant surgeon who sends an additional bill)
• Durable medical equipment (this includes things like crutches or braces that might be necessary after your surgery)
• The recovery room or area in which you are cared for following the surgery
• Your hospital stay if you require inpatient care
• Skilled nursing facility charges if you require extensive rehabilitative care after leaving the hospital but before returning home (here's what you need to know about skilled nursing facility coverage if you have Medicare)
• Part-time nursing care or therapy you may need during your recovery at home

Depending on your insurance, each of these items may have different coverage levels. It is useful to familiarize yourself with what may be excluded.

Out-of-Pocket Cap Limits Your Costs

In the United States, nearly all types of non-Medicare health insurance have to cap in-network out-of-pocket costs at no more than $9,100 for a single person in 2023 (increasing to $9,450 in 2024).

This rule does not apply to grandmothered or grandfathered health plans, and it also doesn't apply to Medicare (Original Medicare does not have a cap on out-of-pocket costs; Medicare Advantage plans must cap non-prescription in-network out-of-pocket costs at no more than $8,300 in 2023). And the out-of-pocket limit also doesn't apply to plans that aren't subject to Affordable Care Act regulation, such as short-term health insurance or health care sharing ministry plans.

But other health plans, including those purchased in the individual/family market (including through the exchange/marketplace or off-exchange) and those offered by employers, are required to conform to the federal caps on out-of-pocket costs. Many of these plans have out-of-pocket costs well below the allowable caps, so you might find that your health plan's out-of-pocket cap is only a few thousand dollars.

As long as you stay in-network, obtain any necessary prior authorization, and receive only care that's covered by your health plan, you can rest assured that your plan's cap on out-of-pocket costs will limit how much you have to pay in any given year, regardless of how expensive your surgery might end up being.

Surprise Balance Billing Protections

You likely know that you should (or must, depending on your plan) select a surgeon and facility that are part of your insurance plan's provider network. And it's also a good idea to check to be sure that everyone participating in your surgery is part of your insurance plan's provider network.

But this is less of a worry than it used to be, thanks to the No Surprises Act, which took effect in 2022. The No Surprises Act protects against surprise balance billing if a patient is treated at a hospital, hospital outpatient clinic, or ambulatory surgery center, which covers most places where surgeries are performed.

But some out-of-network providers are allowed to ask patients to waive their rights under the No Surprises Act. They cannot coerce consent, but they can refuse to provide services if the patient doesn't agree to receive a balance bill.

So if you're scheduling a surgery, it's a good idea to find out how the various medical providers are handling the No Surprises Act. In addition to the surgeon and the facility itself, assistant surgeons, radiologists, anesthesiologists, and durable medical equipment suppliers are a few examples of providers who might be part of the care you receive.

When the Bill Arrives

Even with this knowledge, understanding your hospital bill can be challenging. Formats will vary, but you can expect to see:

• Total charges
• Total insurance payment, if your plan has reviewed the charges before you received the bill
• Total insurance adjustment: The amount discounted by the hospital under its contract with the insurer
• Total patient discounts: An optional discount the hospital may extend to a patient (check with the hospital's business office)
• Total amount due from the patient

Note that you may receive more than one bill, since the various providers involved in your care may bill separately. In each case, you should also receive an explanation of benefits (EOB) from your insurance company, showing how the bill was processed by the insurer.

Don't pay a bill until you're sure you understand it and are certain that your insurer has already processed it. This will ensure that any applicable network discounts have been applied, and that you're paying the correct cost-sharing as stipulated by your insurance contract.

Summary

The amount that a health plan will pay for a surgery will vary depending on the plan and the surgery. It will depend on how much the member owes for the deductible and coinsurance, as well as the cost of the surgery itself. Fortunately, the No Surprises Act now ensures that even if out-of-network ancillary providers are involved in the surgery, most patients will still only have to meet their in-network cost-sharing obligations.

A Word From Verywell

Most health plans will cover most medically necessary surgeries. But "cover" doesn't mean pay for the whole cost, or even any of it. If you have a high deductible and the surgical procedure is minor (ie, it costs less than your deductible), you may find that you have to pay the full cost yourself. But even if that's the case, you'll get the network negotiated rate, which means that you'll pay less than you would have paid if you didn't have insurance.