One of the Essential Health Benefits that all Marketplace plans must cover is Hospital Care, which includes surgeries and overnight stays.
Note: Referral or pre-authorization requirements for surgical procedures differ for every carrier, but most plans seem to require pre-authorization. If your provider is in-network, it’s in their contact with the carrier to obtain any necessary prior approvals before elective procedures.
Here is a general list of surgeries that are covered under Marketplace plans. Please note that cost varies depending on your benefits. This isn't an inclusive list, obviously - Just some examples!
- Total Knee Replacement (TKR)
- Total Hip Replacement (THR)
- Arthroscopy of joint (shoulder, knee, hip)
- Colonoscopy (diagnostic; Preventive colonoscopies are covered at no cost when requirements are met and the procedure is billed by in-network providers with preventative coding)
- Back surgery
- Neck surgery
- Cholecystectomy (Gallbladder removal)
- Cataract surgery
- Dental surgery only when due to accidental injury to sound and healthy, natural teeth
- Surgical procedures deemed medically necessary—that is, surgery to save your life, improve your health, or avoid possible illness
Bariatric surgery is an additional benefit that may be covered under some Marketplace plans depending on which state you live in. Bariatric coverage is required in states that consider it an Essential Health Benefit (there’s currently 23: AZ, CA, CO, DE, HI, IL, IA, ME, MD, MA, MI, NV, NH, NJ, NM, NY, NC, ND, RI, SD, VT, WV, and WY).
Also of note: There is no waiting period between your coverage effective date and utilizing your benefits (such as hospital care).