7 Things Your Health Insurance Doesn’t Cover:

The Affordable Care Act (ACA) now dictates exactly what healthcare insurance providers must cover under the banner of “10 essential benefits”, which apply to individual and small group plans.

That doesn’t mean everything that’s not on the list won’t be covered, that is up to the insurer. To get the best plan you should carefully research what services you yourself require and then shop around for insurance companies accordingly.

Here’s a list of 7 things that generally won’t be covered by default:

1) Alternative Health Practices

“Alternative Therapies” can be a bit of a grey area when it comes to health insurance because the definition is vague. However, massage therapy, acupuncture, and chiropractic care are NOT covered unless there is a specific medical reason given under the context of “medically necessary chiropractic care.”

In action, this means you will only usually be covered if, for example, you recently suffered an injury and these therapies are part of the recovery process. There will also be a limit put on the number of visits you can have.

In other words, you will NOT be covered if you visit a massage therapist, chiropractor or have acupuncture for preventive health reasons or as part of a relaxation/beauty regime.

Chinese medicine, supplements and alternative medicine, health and non-medical fitness products, and other non-FDA approved products and services are not covered.

2) Cosmetic Procedures

As the definition suggests, healthcare is about health and not cosmetic appearance, so any cosmetic procedure you might desire for aesthetic reasons (such as a facelift) will not be covered.

The only exception is certain reconstructive surgeries, such as reconstructive breast surgery following a mastectomy or other procedures required by burn victims etc.

The definition again falls under “medically necessary.”

3) Travel Vaccines

Because travel is considered a choice or a luxury, rather than a necessity, travel vaccines that are required to enter a foreign country or you deem necessary to visit certain parts of the world are not covered. So for example, if you were going on a trip to Africa you might require typhoid or yellow fever vaccine, but you will have to pay for these yourself.

Other medically necessary vaccines such as the flu shot, which is often needed on a yearly basis for those with immune system problems, are covered by Medicare and most insurance plans.

4) Dental, Vision and Eye Care

Dental, vision and eye care are usually only available as a separate plan, an add-on to your current insurance plan, or as part of some Medicare Advantage plans; not part of the standard coverage.

There are some things you should know, however. These plans are not regulated by ACA, which means the provider is not obliged to cover any specific procedures. It will, therefore, be your responsibility to read the small print from your provider to see exactly what they cover.

It’s also worth noting that unless you have some underlying dental, vision or eye conditions, it may actually be cheaper to pay for basic procedures like dental cleans or eye tests upfront than to pay for a monthly insurance policy.

You might also consider a dental loan from a company that specializes in financing such procedures if you want to pay upfront, which may also work out cheaper in the long-run than insurance.

5) Weight Loss Surgery

Medically necessary bariatric surgery (commonly known as gastric bypass surgery) is covered by Medicare and most Medicaid programs, however not all private insurers are regulated to do so – which means you will have to check this yourself.

There are however 23 states that require some weight loss procedures as part of their essential health benefits packages.

If you are considering something like gastric bypass surgery or having a gastric band (which is no longer considered experimental), you should research plans and read the small print to find the best solution for you.

6) Some Medications

While all of you prescriptions have to be covered by insurance, as this falls within the “10 essential health benefits” criteria, individual medications do not necessarily have to be covered. In other words, if there are multiple medicines that do the same thing, it is up to the insurer which ones they include. In total, they must cover at least one drug from each USP category and class.

It’s also important to remember that the underlying drug is not known by a brand name and you may be given what is called a “generic,” rather the one you have seen advertised or has been popularized. Generic drugs are still identical, they are just not marketed with a brand name by the larger drug manufacturers.

So-called “over-the-counter” medication that you have not been prescribed by a doctor is not covered, even if you are using it because you are sick. Neither are alternative medicines or health/fitness supplements (unless you are prescribed essential vitamins like Iron for example).

7) Preventative Tests

Unnecessary ‘preventative tests’ are not required to be covered by health insurance, such as choosing to get blood work done and having something like vitamin D levels measured to check whether your diet is lacking for ‘health and fitness’ purposes.

However, if you have underlying medical conditions that might cause you to be low/high in certain things, these will be covered.

Cholesterol screenings, colonoscopies, and mammograms are specifically covered, but unfortunately, Prostate Specific Antigen (PSA) screenings are not, unless you are considered high risk of prostate cancer or other conditions.

Ultimately, if you want to know exactly what is covered by an insurer or policy, ask them directly or take the time to read the fine print.

About the author

Arnold Smith

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