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What Health Insurance Doesnât Cover: Your Guide
Insurance of any kind can be confusing, but when it comes to medical insurance, itâs really tricky to tell whatâs covered and what isnât. Whether youâre shopping around for a new plan or recently just got on a new health insurance plan, itâs good to know the ins and outs of your health insurance coverage before you end up with a large stack of medical bills that you canât afford. In this article, weâll discuss the things that medical insurance surprisingly doesnât cover so that you can make better decisions about your medical expenses.Â
What health insurance does cover
In accordance with the Affordable Care Act (ACA), the Health Insurance Marketplace must now cover a specific set of services at little or no out-of-pocket expense to you. They are also required to cover at least 10 essential health benefits. These essential health benefits (EHBs) include:
- Ambulatory patient services
- Emergency services
- Hospitalization and surgery
- Maternity and newborn healthcare
- Mental health treatment and substance abuse disorders including counseling and psychiatric treatment
- Pharmaceutical drugs
- Rehabilitation services that provide care for those suffering from disabilities and injuries.Â
- Laboratory services (blood and urine testing, etc.)
- Preventative and wellness services
- Pediatric services
In short, a lot of the basic care that you will get on a regular basis should be covered by your health plan. Most of the time your doctor wonât suggest treatments that are not covered by your insurance. In a lot of cases, they will try to familiarize themselves with your health insurance plan so that they can lead you in the right direction. However, donât leave the all the responsibility in the hands of your doctor. Itâs important that you make time to read through your health insurance policy and look for any holes before getting services.Â
What health insurance doesnât cover
If you have a good insurance plan, most of your basic medical needs will be covered, but you might be surprised to know the services that generally are. Here is a list of services that health insurance does not cover:
- Nursing home services: Most nursing home services are not covered by standard health insurance or even Medicare. However, nursing home care is covered by Medicaid. Many people are confused about this, because they confuse short-term care from a skilled nursing facility with long-term nursing home care. These two things are very different. For example, if you were to suffer from a fall or some other type of injury that required you to get surgery, you would need short-term care in a rehabilitative facility to help you get back on your feet. That kind of care is covered. Full-fledge nursing home care on the other hand, wouldnât be covered because most health insurance providers place time limits on how long they will cover nursing home services. That being said, Medicare will only cover skilled nursing if the patient stayed for at least three days before staying in the skilled nursing facility. Additionally, the patient must be admitted to the facility for the purpose of seeking treatment for a short-term illness or injury as opposed to a chronic one.Â
- The shots you get before traveling abroad: At some point, health insurance companies decided that they would only cover services and procedures considered to be medically necessary, and travel vaccines didnât make the cut. Now, weâre not talking about your standard health vaccines like the tetanus or flu shot; those are covered. But for those of you who like to travel, the cost of your Typhoid or Yellow Fever vaccine is coming out of your own pocket. This rule of thumb goes for the vast majority of health insurance policies, including Medicare.
- Cosmetic surgery: Once again, health insurance policies will usually only cover what is âmedically necessary.â Itâs safe to say that Botox and lip injections will not be covered by your health insurance policy. However, there are certain surgeries that dance on the line between medically necessary and cosmetic. For example, if you wanted plastic surgery on your nose because you thought it was too big, thatâs considered cosmetic. But if you had to get work done on your nose due to issues with your sinuses, then thatâs probably going to be considered medically necessary.Â
- Acupuncture & alternative therapies: The rules surrounding acupuncture and other types of alternative therapies such as chiropractic care arenât as black and white. Coverage for such services like massage therapy, acupuncture, and chiropractic care arenât part of the requirements for most individual health care plans. However, depending on what state you live in, your health insurance plan might cover chiropractic costs. Say you are involved in a car accident that caused you to suffer from back injuries as a result. There is a good chance that your health insurance plan will cover these services. However, if you are a regular at the chiropractor just because you enjoy it, then it probably wonât be. While the standard Medicare plan does not cover acupuncture, there are some Medicare Advantage cans that can. Keep in mind that with most plans who do cover these types of services, there is usually a limit on how many visits you get.Â
- Dental, Vision & Hearing: If you are shopping around for health insurance plans with your employer, note that dental, vision and hearing services are not covered under a regular health insurance policy. If you want to get insured for these services, you will have to buy separate insurance plans for each one. Keep in mind that a lot of times, these insurance policies donât have any limits on how much they can charge you in out-of-pocket expenses, so research different dental offices before receiving services. Some people choose to not include a dental plan at all. If you wear glasses or contacts, however, itâs probably worth looking into your options for vision insurance.
- Weight loss surgery: If youâre considering having weight loss surgery, you might be in luck if you have Medicare or Medicaid. While there is currently not a requirement at the federal level for health insurance plans to cover bariatric surgery, Medicare and many Medicaid plans do cover it. Aside from those two plans, more than half of the states in the U.S. do require there to be at least partial coverage for bariatric survey as an essential health benefit (EHB). Remember that even if the state you live in mandates coverage for this procedure, you may still be responsible for some of the medical bills related to your weight loss surgery.Â
- Preventative screenings: Before we go any further, there are A LOT of preventative tests that are covered by your health insurance policy, but there are some that arenât. This is where things get confusing for a lot of people. For example, mammograms, cholesterol screenings, and colonoscopies will be covered. But if you need to get Prostate Specific Antigen (PSA) screening, it most likely will not be covered.
- Certain medications: Once again, there are a ton of prescription medications that are covered by most health insurance plans, since pharmaceutical services are one of the essential health benefits (EHBs). However, health insurers get to choose what to cover and what not to cover. Most healthcare insurance plans will choose to cover the minimum. This means that they will pick a drug from each class to cover, and not cover the rest. Many times, the generic version of the drug you are prescribed will be covered by your health insurance, while the name brand will not.
What Health Insurance Doesnât Cover: Your Guide is a post from Pocket Your Dollars.
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A Guide to Coinsurance and Copays
Having health insurance makes it possible to receive medical care while only paying a fraction of that careâs true cost. Insurance doesnât cover everything, however. Some of the cost of your care is still up to you to pay, and that cost comes in two primary forms: copays and coinsurance.
What Is a Copay?
A copay is a flat amount of money that youâre responsible for paying for a health care service. Copays typically apply for things like a doctorâs appointment, prescription drug or medical test. The amount of your copay is dependent on your specific health insurance plan.
You can typically expect to pay your copay when you check in for your service, be it an annual physical, dental cleaning or blood test. Copays are typically lower amounts ranging from $10 for something like a generic drug prescription to around $65 for a visit to a medical specialist.
Depending on your insurance plan, copays may not take effect until after you reach your deductible. Your deductible is the amount of money you must pay out-of-pocket before your insurance provider starts to pitch in. Deductibles reset at the beginning of every year.
When you are reviewing your plan information and you see the phrase âafter deductibleâ or âdeductible appliesâ in reference to your copays, thatâs an indication that the copay is only in place once you meet your deductible. On the other hand, if you see âdeductible waived,â thatâs a sign that your copay is in place from the beginning. It may go without saying, but the latter situation is vastly preferable to you.
What Is Coinsurance?
Coinsurance is another method of splitting the cost of medical coverage with your insurance plan. A coinsurance is a percentage of the cost of services. You pay the percentage, and your insurance company foots the rest of the bill. So, if you have a $8,000 medical bill and a 20% coinsurance, you would be on the hook for $1,600.
Coinsurance typically only comes into play after you hit your deductible. Further, you may have differing coinsurance percentages for the same services depending on your provider network. If you have a preferred provider organization (PPO) plan, your coinsurance could be a higher percentage for providers outside your network than it is for providers in your network.
Similarly, your coinsurance may not apply to providers outside your network if you have a health maintenance organization (HMO) plan or an exclusive provider organization (EPO) plan. Thatâs because these plans typically donât provide any out-of-network coverage.
Copay vs. Coinsurance
Copay and coinsurance are very similar terms. They both have to do with portions of the cost of your health care thatâs under your responsibility. Because of that, and their similar names, itâs easy to confuse the two. There are a couple of important distinctions to keep in mind, however.
The most notable difference between copays and coinsurance is that copays are always a flat amount and coinsurance is always a percentage of the cost of the service. Another difference is that some copays can be in place before you hit your deductible, depending on the specifics of your plan. With coinsurance, you have to hit your deductible first.
Bottom Line
If youâre choosing between health insurance plans, make sure to examine the provided copays and coinsurance for each option. While they may not be the most important factor to consider, a high copay can be quite a pain, especially over the course of years of appointments and procedures.
Tips for Staying on Top of Medical Expenses
- One of the best ways to stay ahead of surprise medical expenses is to have an emergency fund in place for just such a situation. If you can manage it, have three to six months worth of expenses stashed away in a high-yield savings account. That way, if youâre dealing with medical bills or have to step away from work, youâll have a bit of a cushion.
- If youâre not sure how an unexpected medical expenses would fit into your finances, consider working with a financial advisor to develop a financial plan. Finding the right financial advisor that fits your needs doesnât have to be hard. SmartAssetâs free tool matches you with financial advisors in your area in 5 minutes. If youâre ready to be matched with local advisors that will help you achieve your financial goals, get started now.
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Health Insurance Myths Debunked
A health insurance policy is essential for anyone seeking to safeguard their future and avoid the catastrophic consequences of high medical bills. Whether you’re buying coverage for yourself or a health plan for your family, it’s important to get complete coverage. But despite this fact, millions of Americans remain uninsured, often because they believe one of the following health insurance myths.
Myth 1: I’m Young and Healthy; I Don’t Need Health Insurance
You’re never too young to start shopping for health insurance plans because you don’t know what’s around the corner. Medical expenses can be astronomical at any age and anyone can have an accident, fall ill or be diagnosed with a serious disease.Â
It’s not pleasant to think about and many people prefer to bury their heads in the sand and live as if they are invincible, but they’re not. No one is.
Health care is very expensive in the United States, there’s no escaping that fact. This is one of the few developed nations in the world where being the victim of an accident or attack could lead to insurmountable medical expenses and essentially ruin your life. You can’t rely on luck and you can’t assume you’ll be safe just because you’re young, fit, and healthy.
In fact, buying at this young age has many benefits, including the fact that you’ll likely clear all exclusion periods by the time you actually need to start claiming.
Myth 2: The Benefits are Lost if I Don’t Renew by the Due Date
You should always try to pay your monthly premium on time, thus avoiding any issues and ensuring you are covered at all times. However, your health insurance coverage does not end the minute you miss a payment.
Insurance companies have a grace period, during which time your policy will remain active. This period allows you to gather the funds needed and to pay your monthly premium, thus keeping your policy active.Â
Typically, this grace period lasts for between 7 and 15 days, but it differs from provider to provider. Check your policy for more details but try to avoid playing fast and loose with your payments as they could be the only thing protecting you.
Myth 3: It’s All About the Deductible
The deductible is the amount of money you pay before the health insurance policy takes over and to many consumers, it is the single most important part of any health insurance policy. However, while it is important to consider the deductible, you should not choose your policies based solely on which one has the lowest deductible.
Look for the sort of cover that they provide and whether this will suit your needs or not, and then focus on the deductible.Â
It’s also important to find the right balance between a deductible that is cheap enough for you to afford when the time comes, but is not so cheap that it sends the premiums through the roof. To do this, avoid focusing on how much your first monthly payment will cost and ask yourself what you would do if you had to pay for a medical expense today.
Would you have an issue paying the deductible? Would it require you to borrow money from friends or family? If so, it’s too high and it’s time to go back to the drawing board.
Myth 4: I Have Insurance from My Employer so I Don’t Need any Additional Cover
If your employer offers any kind of group health insurance cover, take it, but don’t assume that it will cover you for everything you need. Read the small print, look for gaps, and seek to fill those gaps with your own cover.
With your own policy, you’ll also be protected if you lose your life. If anything happens in the time it takes you to find a new job, you could be left to foot the bill, making this an even scarier and more stressful time. But if you’re covered, you can take your time as you search for a suitable role.
Myth 5: It’s Not a Pre-Existing Condition if I Didn’t Know About it
If you have any pre-existing medical conditions you will be subject to an exclusion period, one that may last for up to 48 months. During this time, your insurance company will not pay out for any issues related to this condition and contrary to popular belief, not knowing about the condition is not enough to avoid this exclusion period.
If, somehow, it is proven that you had a medical condition that was simply not discovered at the time you applied, it will still be subject to an exclusion period. The good news, however, is that you can no longer be refused because of pre-existing medical conditions, which means that everyone can benefit from health insurance.
Myth 6: I Don’t Need Health Insurance If I Have a Life Insurance Plan
A life insurance policy can cover you for critical illness, which could be used to cover health care costs. You can also purchase accident and dismemberment insurance to cover you in the event you lose a limb. However, life insurance is designed to pay out a death benefit when you die. It goes to your loved ones, not you, and is therefore not a viable replacement for health insurance.
For complete cover, you should look into getting both life insurance and health insurance. You can find low-cost options for both.
Summary: Common Myths Debunked
If you don’t have any health insurance coverage, it’s time to change that and start looking for coverage today. Take a look at our guide to choosing a health plan to get started. We also have guides on everything from life insurance (term life insurance, whole life insurance, and other life insurance coverage) car insurance and pretty much all other insurance products.
By purchasing all of these together you could even save some money while getting essential coverage! Just remember to do your research, plan ahead, and never settle for less than you need as you may live to regret it in the future.
Health Insurance Myths Debunked is a post from Pocket Your Dollars.
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