How long after getting private health insurance can you get surgery?
July 1, 2014 9:51 AM   Subscribe

I need a jaw surgery and I haven't had any insurance for the past year. I was thinking of paying for individual private insurance, but I've never had to get surgery before so I don't know if there will be restrictions to my getting surgery right after signing on to a policy. What would you recommend and what kind of insurance should I get? I'm generally a healthy person so I barely ever used my insurance back when I had it. I really don't know anything about this stuff.
posted by olivetree to Health & Fitness (7 answers total) 1 user marked this as a favorite
Can you let us know where you live (city/state/country)? Insurance options depend on where you live.
posted by ThePinkSuperhero at 9:53 AM on July 1, 2014

I am assuming you live in the United States, which is a statistically likely assumption that I am comfortable making.

The Affordable Care Act in general prohibits insurance companies that provide ACA-compliant plans from not covering pre-existing conditions (whatever problem you have with your jaw). So, you should get an ACA-compliant health insurance policy, presumably on your state's health care exchange.

Note that you are currently outside the "Open Enrollment Period", so you will have to have a "qualifying life event" if you want to enroll before the next open enrollment period, which is in November 2014 for coverage starting in 2015.
posted by saeculorum at 9:56 AM on July 1, 2014 [1 favorite]

Sorry. I'm in NYC.
posted by olivetree at 9:57 AM on July 1, 2014

The remaining question is whether you will be able to get an ACA-compliant plan at this time. The deadline for getting insurance under the ACA was in March. The next open enrollment period will be in October or November. Until then, many companies have stopped issuing new individual policies. The ACA has a web page on getting health coverage outside Open Enrollment that might be helpful.

Good luck!
posted by alms at 10:06 AM on July 1, 2014 [3 favorites]

Since you're planning for a major procedure, you'll ideally want to minimize the total combined cost of your annual premium and out-of-pocket maximum (oopm), while making certain that your hospital/surgeon/surgery will be covered. Plans with a low oopm will tend to be more expensive, but the income-based tax credit for ACA-compliant plans can be immensely helpful so you should get an idea of where you stand in that regard ( estimating tool). If you don't qualify for a tax credit or it isn't enough to make the low oopm plans affordable, then you'll need to get a handle on what your surgery will actually cost so you can make informed decisions about what paying varying percentages of your bill would actually mean. In that case, you should also pay attention to the insurance deductible, with is a set amount of money you'd have to pay before insurance kicks in at all but does count toward your oopm.
posted by teremala at 11:14 AM on July 1, 2014

I came in to talk insurance, but the advice given here already has been great.

But since you mentioned jaw surgery, is this, by chance for something related to TMJ? TMJ surgery has very low success rates and I would encourage you to seek more conservative treatments and a second opinion before undergoing the surgery.

TMJ surgery, pre-ACA, was nearly impossible to obtain on individual insurance because of this low success rate. I'm not up to date on where it stands with ACA/marketplace plans, but you might want to have a particular diagnostic and procedure code from your surgeon/doctor ready to verify coverage before purchasing. This also allows you to comparison shop for how much you'll owe on this procedure with different plans.
posted by fontophilic at 11:40 AM on July 1, 2014

I'm not an expert but I would say a month. Jaw surgery is normally elective (unless you are in the er because you fell or something) and it takes time for your surgeon to provide proof that you need surgery and get the coverage approved. Also, definitely read the fine print on the insurance plans. Most hmos do not cover any jaw surgery. Many ppos cover jaw surgery. I heard kaiser has the best coverage. And check that they allow surgeries to be done in an outpatient setting (surgeons office) rather than a hospital as that will be a lot cheaper.
posted by puertosurf at 9:31 PM on July 1, 2014

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