Friday, February 16, 2007

Plastic Surgery and Insurance

Plastic surgery is generally covered by insurance only if it is a reconstructive surgery and not a cosmetic surgery.

Reconstructive surgery is 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. On the other hand, cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. (Source: American Medical Association and American Society of Plastic Surgeons (ASPS))

Cosmetic surgery is usually not covered by health insurance because it is elective. Cosmetic surgery is your choice and not considered a medical necessity. Reconstructive surgery is generally covered by most health insurance policies although coverage for specific procedures and levels of coverage may vary greatly.

The general rule insurance companies follow is that if there is a medical reason for the surgery, it will be covered under reconstructive surgery. For example, a patient may need a rhinoplasty due to obstructive breathing. A second patient may want a rhinoplasty because she feels her nose is not perfect. The first patient may have it covered by insurance, the second patient would not.

Most insurance companies will have medical criteria that must be met in order for the surgery to be covered. This is especially true for breast reduction patients. Depending upon height, weight, and medical conditions, a certain number of grams must be taken off each breast.

And even if you are getting the plastic surgery for a medical reason and you have insurance coverage, it does not mean the insurance carrier will pay the full amount of the surgery cost. Depending upon your specific insurance plan, you may have to pay a deductible, a flat-rate co-payment and a percentage-based co-payment.

Consider the example of a woman who is planning to undergo a reconstructive breast reduction (reduction mammoplasty), the surgical fee will be $12,000. Her plan has a $500 annual deductible, and will cover 70% of her covered medical costs. If she hasn't paid anything so far this year in covered medical expenses, she must pay the first $500 of the covered costs of the breast reduction surgery to satisfy her plan's $500 deductible. If her plan cost's share is a percentage-based co-payment of 70%-30%, the carrier will pay 70% of the covered costs of the procedure. Once that is settled, she must pay for 30% of the covered costs, plus any costs for which the insurance plan denies coverage.

If the patient's insurance plan covered the full surgical fee, the cost sharing would look like this:

Reconstructive Breast Reduction Surgery: $12,000
Balance of deductible: $500
Insurance coverage: $11,500 x 70% = $8,050
Patient payment: $12,000 - $8,050 = $3,950

The $3,950 is the patient's responsibility under the percentage-based co-payment arrangement.

It should be noted that the insurance plan may not cover the full surgical fee. Also, sometimes the patient may have to pay in part or full the cost of the prescription drugs.

Needless to mention that had this breast reduction surgery been a cosmetic one, the insurance would not have paid anything even though you had been paying your monthly premiums.

However, if you opt to have the same surgery overseas, say in Mexico, you may have to pay just a fraction of the cost in the US.

At Healthbase, we ensure that you get the best quality treatment for low at our partner hospitals overseas so you never have to worry about being fully insured. Sign up for FREE to obtain your treatment quote and consult with our surgeons about how they can help you with your problem.

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Note: All information shown here has been obtained from publicly available medical resources and is here for reference purposes only. Healthbase does not claim to be a medical professional and does not provide any advice on any issues relating to medical treatment.