"Does OHIP Cover Surgery? Your Comprehensive Guide"
Does Original Health Plan (OHP) Cover Surgery?
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Original Health Plan (OHP) is a health insurance provider that offers a range of plans to suit different needs and budgets. One of the most common questions we receive is whether OHP covers surgery. The short answer is: it depends. OHP offers various plans, each with its own coverage details. Let's delve into the specifics.
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Understanding OHP's Coverage
OHP's coverage for surgery can be broken down into two main categories: inpatient and outpatient surgeries. It's crucial to understand the difference between the two, as they are often treated differently in terms of coverage.
Hip Surgery
Inpatient Surgery
Inpatient surgery refers to procedures that require an overnight stay in the hospital. OHP generally provides coverage for medically necessary inpatient surgeries. However, the extent of coverage can vary depending on the specific plan.
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Bronze and Silver Plans: These plans typically cover 60% to 70% of the cost of inpatient surgery after the deductible is met.
Gold and Platinum Plans: These plans usually cover 80% to 90% of the cost of inpatient surgery after the deductible is met.
It's important to note that some plans may require prior authorization for certain surgeries. Always check with your insurance provider to ensure you understand the specific requirements of your plan.
Outpatient Surgery
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Outpatient surgery, on the other hand, does not require an overnight stay in the hospital. OHP typically covers a wide range of outpatient surgeries, but the coverage can vary depending on the specific procedure and the plan.
For instance, some plans may cover preventive services like colonoscopies at 100% after the deductible is met, while other procedures may be covered at a lower rate. Again, it's crucial to check with your insurance provider to understand the specific coverage for your plan.
What About Pre-Existing Conditions?
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OHP plans comply with the Affordable Care Act (ACA) rules, which means they cannot deny coverage or charge more due to pre-existing conditions. However, there are some exceptions. For example, if you had a gap in coverage, you might have to wait for coverage of pre-existing conditions to begin. Always check with your insurance provider for the most accurate and up-to-date information.
What About Surgeries That Are Not Medically Necessary?
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OHP generally does not cover surgeries that are not medically necessary. Cosmetic surgeries, for instance, are typically not covered unless they are deemed medically necessary. Again, it's crucial to check with your insurance provider to understand the specific coverage for your plan.
How to Check Your OHP Coverage for Surgery
To check your OHP coverage for surgery, you can:
Log in to your OHP member account online.
Contact OHP customer service. The number can be found on your insurance card or the OHP website.
Review your Summary of Benefits and Coverage (SBC) document. This document outlines the benefits and coverage details of your specific plan.
Remember, it's always a good idea to check with your healthcare provider and your insurance provider before scheduling a surgery to ensure you understand the coverage and any potential out-of-pocket costs.
Table: OHP Plan Types and Typical Coverage for Inpatient Surgery
