Will Your Health Insurance Pay for an Elective Surgery?

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. And 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 an elective surgery that’s medically necessary, and your health insurer’s opinion of what’s medically necessary may differ from your surgeon’s opinion.

This article will explain what elective surgery is, and what you need to know in terms of health insurance coverage for elective procedures, including surgery.

Surgeons performing surgery in operating room
Getty Images / Morsa Images / DigitalVision

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.” But they’re not the same thing.

Elective surgery is a surgical procedure you may choose (elect) to have or choose not to have. Some elective surgeries are medically necessary; some are not. But the defining characteristic of an elective procedure is that if you don't have it done, you will not immediately die or suffer grave consequences.

Each health plan, including Medicare and Medicaid, 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.

As we saw in the early days of the COVID-19 pandemic, elective surgeries can be postponed. This is what differentiates an elective procedure from an emergency procedure. Both might be medically necessary and covered by health insurance, but delaying or avoiding an elective procedure is generally an option—sometimes because you or your healthcare provider feel that's the best choice, or sometimes because a pandemic forces hospitals and surgery centers to postpone elective procedures in order to protect public health.

Examples of Elective Surgery and Medically Necessary Surgery

  • Elective and 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 and 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 caused by the gunshot wound.
  • 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, and breathe just fine. The facelift is elective because you can choose to have it or choose not to have it. And most health plans would deny this surgery, because it's not medically necessary. 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 and/or get a referral from your primary care provider, do so.

If your health plan does not agree that your surgery is medically necessary, it’s unlikely to pay for it. But when your doctor seeks prior authorization from your health plan, it will include an explanation of why the surgery is medically necessary. And there's an appeals process that can be used if the health plan disagrees.

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 and/or coinsurance.

But as long as the procedure is covered and you use medical providers in your plan's network, your out-of-pocket charges will be capped at whatever amount your health plan has set as its annual out-of-pocket limit.

(Note that if your charges are incurred at the end of one year and the start of the next year—with a surgery near the end of December and follow-up therapy in January, for example—your out-of-pocket charges will start to accumulate again in January, assuming your plan year follows the calendar year. Original Medicare is different, however, with out-of-pocket costs that are based on benefit periods instead of the calendar year).

Health Plans Sometimes Cover Elective Surgeries That Are Not Medically Necessary

Sometimes a health plan may cover elective surgery even though it’s not technically medically necessary. For example, longstanding federal law requires most private health insurance plans to cover breast reconstruction or breast implant surgery following a mastectomy for breast cancer.

All non-grandfathered health plans (with exceptions allowed for employers' moral or religious beliefs) cover sterilization surgery for women (tubal ligation), as it's required under the terms of the regulations that were developed to implement the Affordable Care Act. Some health plans cover vasectomies, although they are not required to under federal rules (some states do require state-regulated plans to cover vasectomies).

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 (under the ACA, non-grandfathered plans must have both an internal and external appeals process available to members).


A surgery is elective if it is not an emergency. In other words, it can be delayed or scheduled for some point in the future, as opposed to being done immediately. But "elective" does not mean that the surgery is not medically necessary. Most elective surgeries are indeed medically necessary, which means most health plans will consider them to be a covered service.

It's important to understand, however, that "covered" does not mean that the health plan will pay the entire cost of the surgery. Depending on the plan, the patient will generally have to pay a deductible, and after that's met, coinsurance up to the plan's maximum out-of-pocket cap.

A Word From Verywell

If your doctor says you need a surgery but that you can schedule it at your convenience, it's likely considered an elective surgery. Chances are, your health plan will count the cost as a covered expense, although you'll have to pay whatever cost-sharing (deductible, copays, coinsurance) your plan requires. You'll want to make sure you understand the details of what's required by your plan in terms of things like referrals and prior authorization. But your doctor can help you sort out whatever details are necessary to ensure that your surgery will be covered by your health plan.

9 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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By Elizabeth Davis, RN
Elizabeth Davis, RN, is a health insurance expert and patient liaison. She's held board certifications in emergency nursing and infusion nursing.