Surgery Coverage in California

What's Covered

All Covered California plans cover medically necessary surgery, including:

• Inpatient surgery: Procedures requiring hospital admission
• Outpatient surgery: Same-day procedures at surgery centers
• Emergency surgery: Covered even at out-of-network hospitals
• Surgeon fees: The operating surgeon and assistants
• Anesthesia: Anesthesiologist fees
• Facility fees: Operating room and hospital charges
• Post-surgical care: Follow-up visits, physical therapy

Surgery Costs by Plan

Your out-of-pocket cost depends on your plan and whether surgery is inpatient or outpatient: a plan charges a copay or a percentage for the facility and the surgeon, and on some plans the deductible comes first. These are the deductibles and out-of-pocket maximums of Covered California's standard 2027 plans:

Prior Authorization

Most non-emergency surgeries require prior authorization from your insurance:

1. Doctor submits request: Your surgeon's office handles this
2. Insurance reviews: Plan verifies medical necessity
3. Decision (usually 5-15 days): Approved, denied, or more info needed
4. Appeals if denied: You can appeal the decision

Surgeries Often Requiring Prior Authorization:

Inpatient vs Outpatient Surgery

Tips to Reduce Surgery Costs

1. Verify everyone is in-network: Surgeon, anesthesiologist, assistant, facility
2. Ask about surgery centers: May cost less than hospital for outpatient procedures
3. Time your surgery: If you've already met your deductible, surgery costs less
4. Get a cost estimate: Ask your plan for an estimate of your costs beforehand
5. Review your bill: Check for errors and ask for itemization
6. Request a payment plan: Most hospitals offer interest-free options