How Much of My Surgery Will My Health Insurance Cover?

The answer depends on your health insurance company and your surgery

Doctor and Male Patient Discussing Options
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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.

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 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 health-improving surgery. A prime example is breast implants done during or 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:

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

    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 and x-rays, that help your doctor 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 doctors 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 doctor(s) needed to provide it.
    • The surgeon's fee, which typically is separate from the fee for the actual surgery.
    • The recovery room or area in which you are cared for the following surgery.
    • Your hospital stay, if you require inpatient care.
    • 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. Certain services associated with surgery (anesthesia and hospital stay, for example) are more likely to be covered than others (such as at-home care).

    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 patient