Do you know what is covered under your health insurance? Health insurance policies can be very complex and confusing, and many times it isn’t clear which procedures are covered. Many health insurance customers are not sure exactly what is in their policy, what their responsibilities will be, and what their insurance will cover.
In some cases, procedures have to be approved by an insurance company if they are unusual, expensive, or outside of a certain set of parameters. This can slow treatment and cause delays that, in some cases, can increase the expense of the overall treatment or even raise the risk to the patient.
Approvals are needed to help decrease unnecessary and elective procedures that cost insurance companies money and raise the cost of premiums. Some treatments are approved and covered by nearly all insurance companies, such as the addiction treatments offered at Cornerstone in Scottsdale, AZ.
However, patients are often caught off guard or surprised to find that there are some treatments that insurance won’t usually cover. Here are some of the most common things that aren’t covered by typical insurance plans:
Experimental treatments are therapies that have not yet been proven effective or safe through clinical trials. Most insurance companies won’t pay for these treatments because they are not considered to be medically necessary or evidence-based.
In some cases, a treatment is considered experimental because it is approved for another use, but not the use you are planning. In these cases, insurance acceptance can vary with the company, procedure, and situation.
Cosmetic procedures are treatments that are performed for aesthetic reasons rather than medical reasons. Most insurance companies won’t pay for these procedures because they are not considered to be medically necessary. Cosmetic procedures can include plastic surgery treatments such as breast enhancements and nose reductions.
However, sometimes plastic surgery procedures are not considered cosmetic, depending on the situation and your insurance company. For example, many insurance companies will cover breast reconstruction after a mastectomy and plastic surgery after burns or other injuries.
Wellness programs are designed to promote overall health and wellness, but many insurance companies won’t pay for them because they are not considered to be medically necessary. These programs, usually focused on fitness, nutrition, or other similar treatments, are a good way to increase your health and prevent later diseases, especially lifestyle and obesity-related diseases like heart disease and diabetes.
Because many health insurance policies don’t offer these programs, employers and companies are starting to find ways to incorporate them into their benefits packages as a way to help reduce overall expenses and healthcare premiums. For example, many employers offer gym memberships, access to wellness programs, and even on-site fitness facilities to employees who want them.
While some insurance plans may cover certain alternative therapies like acupuncture or chiropractic care, most insurance companies won’t pay for alternative therapies that are not as well-supported by scientific evidence, such as homeopathy or naturopathy. Which therapies are covered, and for what situations, can vary a lot between companies, health conditions, and policies.
For example, massage and acupuncture may be covered to help heal an injury when recommended by your doctor. On the other hand, these treatments may not be covered for other illnesses or if you don’t have a referral. In some cases, no alternative therapies are covered for any situation whatsoever.
While some insurance plans may cover short-term rehabilitation stays or home health care, most insurance companies won’t pay for long-term care in a nursing home or assisted living facility because it is considered to be a personal expense rather than a medical expense.
For people who need this form of long-term care, insurance must be carefully selected or state-funded insurance should be used.
Dental and Orthodontic Care:
Many health insurance plans don’t cover any dental care at all. Others only cover care that is emergency in nature or regular dental screenings. Some companies offer dental care as an add-on to your regular policy.
Orthodontic care is also usually not covered under regular health insurance plans. In some cases, medically necessary orthodontic care, such as bite correction, is allowed.
Treatments That Haven’t Been Pre-approved:
Many insurance companies will only pay for certain kinds of treatments and healthcare visits. Services such as routine care, preventative treatments, and emergency treatments are nearly always covered. However, other services may not be allowed unless they have been approved.
In these cases, a primary care physician may have to refer the patient to a specialist, who can then recommend the treatment. All the steps in this process have to be done correctly and documented or the insurance company may not approve the services and the patient will have to pay out-of-pocket.
Because health insurance is so complex and each company can have different policies, patients should spend a lot of time talking to their insurance company or agent and carefully read their policies before they need treatment.
Finding out what is covered and what processes have to happen in order to get approved is an important step to getting coverage. All of this research should be done before receiving treatment or services to ensure coverage and minimize expenses.