One of the most confusing issues that patients have to deal with is understanding their insurance. This article serves to help my patients understand the basics of insurance coverage as it pertains to oculoplastic surgery which focuses on surgery on the eyelid, tear duct and eye socket.
Cosmetic vs Functional Surgery
There are two broad categories of surgery: Cosmetic Surgery and Functional Surgery. Cosmetic surgery is focused on making you look better or improving your appearance. Functional surgery solves a problem like removing cancer, improving vision, reducing irritation and so on. Cosmetic Surgery is never covered by insurance, Medicare or Medicaid. Functional surgery may or may not be covered by insurance depending on your plan. Some plans cover more functional surgery than others.
Functional combined with Cosmetic Surgery
Some patients may elect to have cosmetic surgery along with functional surgery.
Cosmetic Surgery alone
Again, cosmetic surgery is never covered by insurance.
Functional eyelid, eye socket, and tear duct surgery: What does insurance cover?
Insurance coverage for functional surgery is dependant on the plan. Some plans cover more functional problems than others. Most plans for example cover some functional issues such as eyelid cancer or removing a ruptured eye. Other functional problems such as a drooping eyelid or excess skin may or may not be covered depending on the individual plan.
Medicare is insurance for disabled patients and people over 65. Alone it covers 80% of costs associated with any surgery. The remaining 20% of the bill is the patients responsibility but some patients get a “secondary insurance” to cover that as well.
Medicare HMO as private insurance plans that get money from the government to cover medicare patients. As a result, they cover certain things like medicines that Medicare doesn’t cover. That being said, when it comes to elective surgeries like eyelid surgery, Medicare HMOs generally are very restrictive as to what they cover. There are surgeries that Medicare HMOs will not cover that Medicare will cover. The patient trades the costs of medications for not being able to get certain elective procedures. Medicare HMO is something a medicare patient can choose to join. Unfortunately when these patients need an oculoplastic surgery, that is where they can be frustrated because it is not covered.
Medicare coverage for functional
Medicare has strict guidelines for what they cover. In eyelid surgery for example the problem has to be enough to be causing a vision issue. Appearance improvement is never covered by Medicare.
Medicaid is a government insurance for patients below a certain income level. It covers most of the costs of surgery and the copay a patient has to make is usually minimal.
Kaiser is a closed insurance system. They get money from patients and have their own doctors, nurses and operating rooms for procedures. Like any insurance company, it is not in their interest to pay out more money than they get it. Some Kaiser offices do not have oculoplastic surgeons and send the cases out to private doctors. Since the costs of these surgeries that are sent outside the Kaiser system are expensive Kaiser is incentivized to not send those cases outside. In Colorado currently, Kaiser has one oculoplastic surgeon for all their patients in the state.
Private insurance can vary on the coverage of oculoplastic procedures. The different carriers (Blue Cross Blue Shield, United Health Care, Aetna etc.) have their own guidelines that can vary from carrier to carrier.
What does coverage mean?
Insurance coverage for a procedure or problem means that it falls under the insurance plans payment guidelines. That does not mean that insurance pays the whole bill. It means that the surgery or procedure falls under the insurance plan and how much they pay is dependant on those plans guidelines.
A deductible is the amount of money that the patient is responsible for before insurance pays anything. Depending on the plan, one’ deductible can be $100 or can be $10,000. I tell patients that when it comes to health insurance there is not situation where you get something for nothing. What that means is if a $200 a month plan probably has a really high deductible but a $2000 a month plan may have a lower deductible. So..if you need a procedure and have a $200 a month plan, you will probably have a huge deductible and a giant bill. If you pay a lot every month for insurance you are more likely to have a lower deductible before insurance pays.
Once the deductible is met, insurance starts to pay part of the bill. The rest is a “co-pay”. The co-pay can be a percentage (20% or 10%) or a fixed flat fee (like $250 for any procedure). It is important to realize that once the deductible is met, the patient (depending on their plan) may have a co-pay.
Patients who have insurance have a negotiated rate. So if I charge $1000 dollars to repair a laceration of the eyelid, Aetna may require me as a provider to only charge $750. Their deal is that I can see Aetna’s patients and hopefully make it up on volume.
Lets use an example. Michael Knight is a patient who recently got into an auto-accident when his car KITT turned over. He has an eyelid laceration. He also has Aetna which has a $500 deductible and 20% co-pay. He has his eyelid laceration repaired which I normally charge $1000 for.
First, the eyelid laceration is not cosmetic but functional because there is a risk it can get infected and then damage the eye and face. Aetna and I have an agreement that I charge their agreed rate of $750 so $250 would be deducted off the bat. Of the $750 that is functional surgery that would fall under insurance coverage. So Aetna is covering it but what does that mean for Michael exactly?
Michael would have a $500 deductible which is responsible for before Aetna pays a thing. That leaves $250 of the bill of which Michael as a 20% copay or $50 which he is responsible for. So for the bill, Michael would pay $550 and Aetna would pay $200.
As a patient it is important to know your specific plan. There are literally 1000s of plans and our offices helps people to understand their bill as a courtesy but ultimately it is their responsibility to know. I hope this helps you understand insurance and eyelid surgery.