Does Health Insurance Cover Jaw Surgery?
If you need to get jaw surgery, the costs can be quite high and you’ll definitely end up hoping that your health insurance will cover it. There are a number of reasons why you may be getting jaw surgery, and your reason will determine whether or not your insurance will cover it.
If you are getting the surgery performed because of a broken jaw due to an accident, the insurance company will probably cover it. Many insurance plans will also cover the surgery if it is due to an overbite, underbite, or TMJ (a.k.a. “lock jaw”) that is causing lots of problems. If you are getting jaw surgery for cosmetic reasons, however, the procedure will more than likely not be covered by your plan.
Would jaw surgery be covered under my medical or dental insurance plan?
You may think that surgery of the jaw would be covered under your dental insurance, especially if the surgery is due to under or overbite issues. However, it is considered to be a medical procedure, so you would be using your health insurance plan to cover all of the expenses.
Surgery of the jaw can costs thousands of dollars, so it helps a lot if your health insurance helps to cover the expenses. Surgery of just the lower jaw can cost anywhere from $6,000 to $7,000, while upper jaw surgery often costs more than $7,000. You also need to take into account other costs such as lab and hospitalization fees.
What kind of plan do you have?
One of the biggest indicators of whether or not jaw surgery will be covered, as well as what kind of care you will receive, is the type of insurance plan that you have. If you have an HMO (Health Maintenance Organization), and you have full coverage, there is a pretty good chance that jaw surgery will be covered.
Keep in mind, however, that you will need to use a surgeon that is a member of the HMO. You also may not be able to choose which surgeon to use, as this is often assigned to you by the insurance company.
Although there are some very qualified doctors who join HMOs, the surgeon who you are expected to use for jaw surgery may not have the specialized skills or expertise that you would like them to have. If the first surgery does not go according to plan, you may be forced to go back for additional surgery or therapy.
If you have a PPO (Preferred Provider Organization), you will have more options as far as which surgeon you use, but you may not have full coverage. If you choose a provider who is in the network―otherwise known as a preferred provider―you will have better coverage such as a lower deductible, lower co-pays, and a lower out-of-pocket maximum.
You may choose someone who is not a preferred provider. It may be someone with the expertise that you are looking for or a surgeon whom you have known for a while and trust. If you go this route, your health insurance will help cover your expenses but the coverage will be less. Your deductible is often higher out of network, and co-pays are higher as well.
With some insurance plans, jaw surgery may only be covered in certain situations. If it is an emergency, such as a jaw broken in an accident, it will probably be covered. However, if it is just a discomfort or an aesthetic thing, it may not be covered by your insurance benefits.
Should you have someone else contact the insurance company on your behalf?
Because insurance plans can differ so much, the best way to know if your jaw surgery will be covered or not is to contact the insurance company directly. You, yourself, can always place a call using the toll-free number located on your insurance card.
When you call, however, be aware that the person with whom you will be speaking usually knows nothing about the procedure that you are asking about. He or she will be giving you answers based on general information and usually what will be the most beneficial for the insurance company rather than for you.
If you call and get a denial for coverage, especially if you have read through your benefits and believe that it should be covered, it may be best for someone else to call. Your surgeon’s office should have a person who is in charge of insurance billing.
Because it is this person’s job to deal with insurance companies and she likely knows all of the ins and outs of what it takes to get a procedure covered, she will be much better equipped to speak with a representative at your insurance company.
One of the biggest reasons for insurance coverage denial is that the procedure is not medically necessary. Your surgeon’s billing expert can explain why the procedure is necessary so that it will be covered. And, because the office wants and needs to get paid, they will work hard to make sure that you get the appropriate benefits covered.