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.
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.
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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