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What Health Insurance May (or May Not) Cover

What Health Insurance May (or May Not) Cover

April 19, 2024

Health insurance plays a pivotal role in safeguarding our well-being and providing financial support in times of need.

However, these plans can differ significantly in terms of what their coverage includes, making it potentially complicated to understand their scope. Here’s a closer look at some of the most common services and procedures that may or may not be covered by your provider.

 

What’s typically covered

Preventive care

Many insurance plans fully cover preventive services such as vaccinations, screenings, and annual checkups. These services may look different for men, women, and children, but they’re all aimed at catching potential health issues early and promoting overall wellness, thus preventing more expensive treatments later.

Hospitalization, medical services, and emergency care

Hospital stays, surgeries, and medical treatments deemed necessary for the diagnosis and treatment of illnesses or injuries are typically covered by health insurance. This includes doctor’s visits, diagnostic tests, and more. Emergency medical care, such as ambulance services and visits to the ER, is also generally covered which can help ensure you get the right treatment when you need it the most.

Mental health services

While the coverage for these services differs, many insurance providers do offer some for therapy, counseling, and even inpatient mental health treatment. Just make sure you select a mental health professional who accepts your insurance or look at your insurer’s list of in-network ones.

Maternity and newborn care

Prenatal care, labor, delivery, and newborn care are deemed essential health benefits, which means that all health insurance providers have to cover these services. (This includes private insurance companies, though the specifics for their coverage can differ.) Most of these plans also provide breastfeeding counseling, support, and equipment after the birth of a child.

Prescriptions

Most providers help with the cost of prescription drugs, but it varies from provider to provider. This means that not only will the cost differ but the medications that are covered as well. You can check with your provider for a list of what medications are included and what the out-of-pocket cost is.

 

What might not be covered

Dental and vision care

These aspects of health care require separate policies as they are not typically included in standard health insurance plans; some providers may offer coverage for children but not for adults.

Certain specialized services

Some policies might not cover specialized services, such as fertility treatments, or alternative therapies like acupuncture or chiropractic care. It all depends on what each state defines as essential to its health care benefits. For instance, someone who visits a chiropractor due to a back or neck injury may likely be covered since it could be medically necessary.

New technologies and experimental treatments

If a treatment or technology is considered experimental, unproven, or not widely accepted by the medical community, your insurance company may decline coverage. Providers typically wait for more data to support the added benefit of these technologies or treatments before offering coverage.

Cosmetic procedures

Most health insurance policies do not cover cosmetic procedures that are not medically necessary, including laser hair removal, rhinoplasty, and other plastic surgeries done for purely aesthetic reasons. The cost would have to be paid for entirely out of pocket.

Long-term care

Health insurance generally doesn’t cover long-term care in nursing homes or assisted living facilities, which are often required for elderly individuals or those with chronic illnesses. Medicaid can help cover the cost of this care, but since not everyone qualifies for it, many are left to pay for it out of pocket or through separate long-term care insurance.

Understanding the scope of coverage provided by your health insurance policy is vital for making informed health care decisions. While most plans cover essential medical services, the specifics can vary widely. Make sure you carefully review policy documents, ask questions, and seek clarification from your insurance provider as needed.


   

Important Disclosures

Content in this material is for educational and general information only and not intended to provide specific advice or recommendations for any individual.  To determine which health insurance product(s) may be appropriate for you, consult your financial professional prior to purchasing.

This article was prepared by ReminderMedia.

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