Health Insurance and Cosmetic, Plastic & Reconstructive Surgery
This guide provides information on health insurance coverage for cosmetic, plastic and reconstructive surgery procedures.
Does Health Insurance Cover Cosmetic Surgery?
The coverage provided by health insurance companies depends on the particular contract plans which they offer. Each company compiles its own insurance contracts which specifically include and exclude certain medical costs. With respect to plastic surgery, many of these plans do not cover cosmetic surgery but will provide funding for reconstructive surgery. The terms are specifically defined in the insurance plan.
Many insurers use the standard definitions in their insurance plans which are taken from the American Medical Association and the American Society of plastic Surgeons (ASPS):
- Reconstructive surgery - performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
- Cosmetic surgery - performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.
Which Cosmetic Procedures Are Covered by Health Insurance?
Trying to interpret a health insurance plan can be complex. A procedure may be deemed cosmetic (such as eyelid surgery) but may be medically necessary in order to restore function or eliminate a medical problem (such as vision). The insurance company will need to assess your individual circumstances to determine whether the procedure is covered by your particular contract.
Examples of where cosmetic surgery may be covered include:
· Ear surgery (otoplasty) where the ear or ears are deformed due to birth defects, disease or injury.
· Hand surgery to treat conditions such as rheumatoid arthritis, dupuytren’s contracture, carpal tunnel syndrome, fused fingers and other deformities.
· Nose surgery (rhinoplasty) to correct problems with breathing.
· Facial surgery to restore harmony to the face where deformities have occurred due to paralysis or deformities in the head, neck or facial muscles.
· Cleft lip and palate repair.
· Breast reduction - usually only covered if large breasts are causing back pain or other conditions.
· Breast reconstruction after mastectomy due to breast cancer. This may include tissue expansion.
· Blepharoplasty where the drooping eyelid is obstructing your vision.
· Abdominal surgery to alleviate back pain, sores and hernia.
These are examples of procedures which could border on being cosmetic. Surgery may be considered as reconstructive in the insurance policy plan if it alleviates certain medical problems. You should consult with your insurance plan manager to ensure your procedure is covered and have this approved in writing before you proceed with any surgery.
How Much Do I Pay If I Have Health Insurance?
Health insurance plans generally do not cover the whole cost. Most contracts require the patient to contribute (co-pay) some of the costs. If a plastic surgery procedure is covered by the plan, the amount payable by the insured (you) is worked out using one of these methods: deductible, flat-rate copayment, percentage-based copayment or a combination of these.
With a deductible, the plan stipulates a certain amount which you must pay toward plastic surgery before the insurance company pays any benefits. This ranges between $100 and $500 but can be higher. The insurer then pays a percentage of the covered medical costs (usually between 70-85%, depending on your contract).
A flat-rate co-payment requires you to pay a defined share of the medical costs, depending on the nature of the cost. For example, the plan may stipulate that you pay $20 toward a doctor’s consultation with the insurance company paying the balance.
A percentage based co-payment (usually also combined with a deductible requirement) stipulates a certain percentage to be paid by you and the insurance company. For example, you may be required to pay 20% of the office visit charge and the insurer pays the remaining 80%.
If you are considering cosmetic, plastic or reconstructive surgery don’t just assume the costs are covered by insurance. Make sure you speak with your surgeon and the insurance company representative before making any decisions. Have the procedure approved in writing by the insurer confirming the portion they must pay.