Does Health Insurance Cover Elective Surgery?
Health insurance sometimes covers elective surgery, but it depends on your plan and the procedure.
"Elective surgery" just means a surgery that isn't an emergency or urgent situation. Your plan probably covers elective surgeries that you need to maintain or improve your health. But insurance doesn't usually cover elective surgeries that are optional, like facelifts.
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Does health insurance cover elective surgery?
Health insurance doesn't usually cover optional elective surgeries.
But "elective" doesn't always mean optional. Some elective surgeries are medically necessary and others aren't. Health insurance will usually cover medically necessary elective procedures, like a knee replacement. The best way to find out if your surgery is covered is to talk to your doctor and health insurance company.
What is elective surgery?
Although most people think elective surgery is the same as optional surgery, it's not. Elective surgery is any surgery that can be scheduled and isn't urgent or an emergency. It includes procedures that are medically necessary, like knee replacements, and ones that are optional, like tummy tucks.
Determining whether or not a surgery is medically necessary can be hard. For example, getting your tubes tied, a form of permanent birth control, may not be medically necessary if there is no underlying health issue. But health insurance companies are required by law to cover it.
If you need elective surgery, ask your doctor for the name of the surgery and the billing code. You can take that information to your health insurance company and find out if your procedure is covered.
Elective vs. emergency surgery
Surgery can be divided into two main types: elective and urgent/emergency.
Elective surgery is scheduled in advance, while urgent or emergency surgery needs to happen quickly.
Elective surgery
Elective surgery includes optional surgeries, but it also includes medically necessary surgeries. All "elective" means is that the surgery isn't urgent and you can wait to have it.
Elective surgeries that are not medically necessary include:
- Breast augmentation
- Breast reduction
- Optional facelifts
- LASIK eye surgery
- Liposuction
- Optional rhinoplasty
Medically necessary elective surgeries include:
- Bariatric surgery
- Cataract surgery
- Knee replacement
- Tonsillectomy
- Tubal ligation or removal
- Vasectomy
Urgent or emergency surgery
Urgent or emergency surgeries have to happen quickly to protect your health or set you on the path to recovery. A medical situation that requires urgent or emergency surgery could be life-threatening or become life-threatening if action isn't taken. Urgent or emergency surgery is always medically necessary.
Urgent or emergency surgery might be needed if you have appendicitis, experience a heart attack or stroke or are hurt in a car accident.
How much does elective surgery cost?
The cost for elective surgery depends on the type of surgery you need.
Costs can vary drastically even for the same surgery, depending on where you live, the hospital you go to and your specific medical situation. For example, some people may need more anesthesia than others, which is likely to add to the price.
And if your elective surgery is optional, you'll probably pay the full price yourself, while insurance will pay for some of the cost for medically necessary elective surgeries.
Surgery | Approximate cost |
|---|---|
| Vasectomy | $1,661 |
| Tonsillectomy | $2,392 |
| LASIK | $1,800 to $2,295 per eye |
| Cataract surgery | $3,500 to $7,000 per eye |
| Breast augmentation | $4,294 |
You'll likely pay more than just the cost of the surgery. You'll also probably have charges for medications, surgical tools and time spent in recovery. To better understand how much you could pay, talk to your doctor and hospital and ask for the billing codes they plan to use for your surgery. But don't be surprised if you see more charges on your actual bill. It can be hard to estimate exactly what will be needed during your surgery.
Sources
Sources for this article include the Centers for Medicare & Medicaid Services (CMS), Johns Hopkins and the University of Tennessee Medical Center.
Surgery costs are from:
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