Typical Insurance Limitations and Exclusions
Polices will vary quite a bit on their limitations and exclusions so it’s always very important to read the actual policy (not the marketing information) carefully before making a selection. Here are some limitations and exclusions common for many health insurance policies:
* Pre-existing conditions
Most health plans will have waiting periods of six months to a year for pre-existing conditions if you have had a lapse in health insurance coverage that’s longer than 63 days. For example, if you’re diabetic and leave your job but don’t begin a new job right away, you would have to pick up an individual insurance policy or find coverage somewhere else (through a spouse’s employment, for instance) in order to avoid a waiting period with your next policy.
* Cosmetic surgery
Health insurance rarely covers cosmetic surgeries. Usually they must be for reconstructive purposes after an injury or due to a birth defect. They may also be covered if a doctor states that there’s a medical need for it such as a reconstruction of a clef palate. That means that the face lift or liposuction that you have your heart set on must be paid out of your own pocket.
* Non-traditional treatments
Alternative and complementary medicine often isn’t covered by health insurance. Alternative medicine is defined as treatments that are used in place of conventional medicine and complementary medicine refers to treatments and procedures that are used together with conventional medicine. These types of treatments include acupuncture, yoga, acupressure, massage and biofeedback. In some health insurance plans, even chiropractic treatments can fall under alternative medicine and therefore isn’t covered. These services often aren’t covered as they’re considered by health care companies as experimental or non-traditional in nature.
* Home care and private nursing care
Home care and private nursing expenses are some of the most common expenses that aren’t covered under your insurance plan. According to the CDC there are over 1.4 million patients using home health care with the average patient needing at least 60 days of treatment. Without any coverage, these health care expenses can add up fast and end up bankrupting patients and their families.
* Mental health treatment
Some plans cover mental health treatment as well as drug rehabilitation. Although, some only cover substance abuse if it co-occurs with mental illness. To get access to these types of services you may be required to get a referral from your regular doctor first. Mental health and substance abuse services may also be offered through an employee assistance program (EAP) if your employer has one.
* Common Drug Benefit Exclusions
In addition to the procedures, treatments, and surgeries discussed above, many exclusions fall under drug benefit exclusions. Many of the drug benefits that are excluded can be included in the same cosmetic or nontraditional categories as those mentioned above. Drugs used only for cosmetic purposes usually aren’t covered by your plan. These can include hair growth stimulants and supplements for clear skin or strong nails. Non traditional drugs like food supplements and any drug considered experimental are usually not included in your plan either. Like elective abortions, drugs that are used to abort a pregnancy also aren’t covered for the same political reasons.
Along with limitations and exclusions in your health insurance policy, waiting periods can also affect your overall health care. Find out more about how these waiting periods work and how some can be eliminated all together.
Insurance Waiting Periods
Waiting Periods
The idea of a waiting period in the world of health insurance may seem simple enough: It’s the period of time specified in a health insurance policy which must pass before some or all of your health care coverage can begin. However, the definition is just the tip of the iceberg. Underneath are the types of waiting periods, the rules that apply to each and how they each apply to a given type of health insurance plan.
In general, there are three main types of waiting periods that you encounter in health insurance: employer waiting periods, affiliation periods and pre-existing condition exclusion periods.
* Employer Waiting Period
The most common is referred to as the employer waiting period and is found in an employer group plan in which a new employee must wait a given time period, often within three months, before being eligible for health care services. This waiting period is imposed by the employer and is usually done to avoid hit and run behavior by their new employees, in which they file a large claim right after joining, and then quickly leave the company.
* Affiliation Period
A waiting period that’s imposed by an HMO and not an employer is referred to as an affiliation period. This type of waiting period can’t last longer than three months and has specific rules attached to it.
* Pre-existing Condition Exclusion Period
A pre-existing condition exclusion period is a type of waiting period that involves those who have a condition during the six months prior to signing up for health insurance. This type of waiting period means that your insurance coverage can be limited or excluded for any pre-existing condition. The length of this type of waiting period can vary from one to 18 months. However, once you’ve proven that you’ve had uninterrupted insurance previous to your current plan, this insurance coverage can be added up and credited toward any pre-existing condition exclusion you may have. In fact, if you had at least one year of group health insurance at one job and then received health insurance at a new job without a break of more than 63 days, the new health insurance plan can’t impose a pre-existing condition exclusion on you.
Selecting Your Policy
Whether you’re trying to decide which plan to get through your employer (since they often offer several choices) or you’re trying to decide on an individual health plan, you need to think first about your needs.
* Do you want a plan that covers preventive care like annual check-ups? Remember that most fee-for-service plans don’t cover these visits, but managed care plans do. It’s particularly important to consider this aspect if you have (or are planning to have) children.
* How healthy are you? If you need a low premium and are healthy, you might consider a plan with a higher deductible. Keep in mind that accidents happen, however, and a single hospital stay could wipe out your savings and put you into debt. Think about how much money you would be able to put toward medical expenses if it should become necessary.
* Do you have a specific doctor or hospital you want to be able to use? Remember that managed care plans use networks of doctors, and unless your doctor is in that network you’ll pay all or some of the bills whenever you see him. If a specific doctor (or doctors) is necessary, you might need a fee-for-service plan.
* How important is it to you to have easy access to specialists? Many managed care plans require a referral from your primary care physician before you can see a specialist. If they don’t feel it’s necessary, then you’ll be paying for the visit out of your own pocket.
- health.howstuffworks.com -