Insurance coverage for Orthognathic Surgery

[Ilokaners]

I will be having both upper and lower jaw surgery next month and I'm really nervous about the cost. My insurance only pays a maximum of $5,000 and my total cost is almost 15K. I may have to refinance my home just to pay for this. I'm curious as to what insurance coverage or hospital financial assistance experiences everyone has had. Who knows of the best insurance for orthognathic surgery?

[Nozzelnut]

It's going to depend on which plan you have. There's so many different options depending who your carrier is, what level plan you're in, co-pays, deductibles, in network vs out of network.... Impossible to say because that plan might not be available in your area. Some plans cover jaw surgery for one reason but not others...

Talk to your surgeon; they may have an out patient setting where they can still have your surgery, but with a great savings for you. Or call the hospital and talk to their finance folks. They might have different pricing if you were to pay cash.

[sirwired]

A $5k medical policy limit? That's pretty low. Are you sure that you aren't referring to your dental policy max, instead of your medical? (Medical covers orthographic surgery, not dental insurance.)

I think the new ACA-standard policies available through the insurance exchanges cover orthognathic surgery if you meet the medical necessity criteria of that particular insurer, but I'm not totally sure. An individual policy outside of the ACA will almost certainly refuse to cover it because of pre-existing-condition exclusions. Coverage by employer-provided group policies varies widely; most will cover it, some exclude it.

[Ilokaners]

Yes, unfortunately it is a 5K medical insurance limit under the Regence Uniform plan. I'm trying to figure out right now the type of payment plans my hospital provides. I'll ask some follow up questions once I know more info. Thanks for the reply folks!

[Alicia110613]

I hear that many large hospitals provide a discount to patients who are paying completely out of pocket - i.e. the specific hospital I talked to is around 30% discount, I believe, for expensive inpatient procedures like this.

[Ilokaners]

I spoke to the hospital and they said that my out of pocket payment is:


$6,000 Hospital/facility fee
$1,200 Anesthesiologist (may be more in case of complications)
$7,200 Surgeon fee (final cost after -5,000 from insurance)

My hospital financial counselor mentioned that if I don't pay the up front cost of 6k, the surgery could cost me nearly 40-50k. Basically it's the best option. When put in those terms, I am more than happy to pay the 6k. Without insurance helping, my out of pocket cost would have been nearly $20,000. I took out a bank loan to cover the cost.

[Alicia110613]

Sorry to hear that =(. It's a lot of money for sure. Looks like your hospital/facility fee is lower than the typical insurance contract rate tho so it seems pretty reasonable... medical costs are just so terribly high in the U.S.