Health Insurance

What Types of Surgeries are Covered by My Health Insurance?

Girisha Bharadwaj
Girisha Bharadwaj19 Apr 2022

Many health insurance plans fully or partially cover surgical procedures deemed ‘medically necessary’ by a healthcare professional. Each year, around 15 million Americans undergo surgical procedures. If you plan to get surgery, it is important to ensure it fits within your health budget. Most people depend on their health insurance to cover the cost of surgery. 

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What is considered ‘Medically Necessary’

Medicare defines ‘medically necessary’ as “Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.” It is a term used in the healthcare insurance industry to describe the coverage offered by a health plan. Every health insurance company has its own policies to identify what is a medically necessary service. Typically, these services are:

  • Provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease
  • Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease
  • Within the generally accepted standards of medical care in the community
  • Not solely for the convenience of the insured, the insured’s family, or the provider

Elective vs Necessary Surgeries

An elective surgery is a procedure that the patient can choose to have or not have. It may be medically necessary or it may not be. This classification depends on the patient’s medical professional, their insurance company’s policies, or in the case of Medicare or Medicaid, on the federal government. Even if a procedure is elective, most health insurance plans will pay for them, as long as they are deemed necessary.

How to Find Out If My Surgery is Covered by My Health Insurance

To find out if your surgery is covered by health insurance, you should review your Summary of Benefits and Coverage (SBC). The SBC of a health plan is a detailed document that contains all the costs, benefits, covered healthcare services, and other relevant information about the plan. The Affordable Care Act generally requires all health insurance companies to provide their customers with a SBC of their preferred plan. Make sure to read through this document carefully to find out if your plan offers coverage for your surgery or any related supplementary costs.

Every health insurance plan, even within the same company, has a different set of benefits and coverage it offers. Some plans are more inclusive than others and might cover (partially or completely) the cost of your surgery. Other plans might be more complex as they may cover costs of the procedure and anesthesia, but not cover other supplementary costs like equipment, follow-up visits, or hospital stays. It is important to figure out exactly what part of the total cost you would have to bear to have your surgery. 

What if My Procedure is Not Covered by My Health Insurance Plan

It can be stressful to find out your health insurance does not cover the cost of your surgery. Maybe your surgery is not classified as ‘necessary’ or your insurance company does not offer such coverage. Either way, the cost for the procedure might entirely come down to you. In that case, there are a few options you can explore.

Pick The Best Deal

If your health insurance does not cover the surgery, look into the many doctors and healthcare practitioners in your network who offer that procedure. Different clinics, hospitals, and surgeons often charge different amounts for the same service. Do your research and make sure you pick a facility that offers you the most affordable option. 

Set Up a Payment Plan

Many hospitals and surgeons offer payment plans for patients who are not able to afford their medical costs upfront. A payment plan is a formal agreement between the patient and the medical institution in which the patient makes monthly payments over a period of time to offset the full cost of their bill. 

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Get International Treatment

Healthcare costs in the United States are among the highest in the world. This is why some people try to seek healthcare services in other countries, as it is almost always less expensive as compared to the States. This is often also referred to as ‘Medical Tourism’. 

Every year, millions of Americans travel to nearby countries such as Mexico, or other countries in Central America in search for alternative options. Make sure to consult a medical professional before pursuing Medical Tourism. As warned by the CDC, getting medical treatments abroad can entail various risks. 

Change your Insurance Plan

If your current insurance does not offer coverage for your surgical costs, you can explore your options and look for a more inclusive healthcare plan. For instance, if you are married and your employer insurance does not cover your surgery, but your spouse’s insurance does, you can save money by switching plans. 

Average Costs for Common Surgeries

Surgical procedures are by far the most costly service in healthcare. When a patient pays for surgery, they don’t just pay for the procedure, but also the physician, the anesthesiologist, the equipment, operating room, medication, and the hospital room. Here is a list of most common ‘medically necessary’ surgeries and their average cost in the States. 

Average Cost of Common Surgeries

Surgery TypeAverage Cost (USD)
Heart Valve Replacement170,000
Heart Bypass123,000
Spinal Fusion110,000
Hip Replacement40,364
Knee Replacement35,000
Angioplasty282,000
Gastric Bypass25,000
Cornea17,500

Surgery Costs Frequently Asked Questions (FAQs)

Below we answer some frequently asked questions about health insurance plans.

Is surgery expensive with health insurance?

If your surgical procedure has been deemed medically necessary by your healthcare practitioner, or as ascertained by your health insurance policy, then your health plan will offer at least partial coverage. This can help make surgery more affordable for you. This is why it’s important to get a health insurance plan that fits your needs. 

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Which health insurance company has the highest customer satisfaction? 

While it is hard to pick one company with the best ratings, there are a few top contenders which have shown consistent success in the consumer market. Aetna, Blue Cross Blue Shield, Cigna, Humana, Kaiser Foundation Health Plan, and United Healthcare are some of the most popular names on the list. 

Best health insurance plans in New York City? 

The best health insurance plan is one that fits your specific health needs. To find the plan that is best for you, make sure to do your research. Learn about what is available in your area, benefits and coverage offered, how much premium and deductibles can you afford, and which tier serves your needs the best. Find more information about insurance plans in NYC here!

Does Medicaid cover surgeries? 

Medicaid coverage varies by state. While each state has different sets of healthcare services which are covered under their plans, emergency surgeries are always covered by Medicaid. Elective surgeries are also covered once the patient meets certain health requirements. Other procedures, such as cosmetic surgeries, are not considered medically necessary and so are not covered. 

What is the difference between outpatient and inpatient surgery costs? 

You are considered an inpatient if you stay a minimum of one night at the hospital after getting your medical procedure. However, if you are deemed stable and leave the hospital post-surgery, you are considered an outpatient. A survey conducted by the CDC, found that the majority of surgeries conducted in the States are outpatient. A variety of factors influence the net cost of a surgical procedure, but generally inpatient surgeries are found to be more expensive than outpatient surgeries. 

Bottom Line

Take some time to review your personal health insurance coverage to find out what your plan covers. Surgeries are among the most expensive medical services so it is important to find the best possible deal when it comes to cost of service and insurance coverage. 

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