14 Things You Won't Believe Your Health Insurance Doesn't Cover
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Most health insurance policies will not cover elective surgeries and treatment or cosmetic surgeries, treatments and medications. What is deemed medically necessary is usually covered, unless it’s a brand new medication, service or technology that has not been around long enough to justify a much steeper price than its substitute. If you are considering a procedure, device or medication and are unsure if it’s covered, look at the list below for clarification. Remember that if a provider does see a real reason to use a drug, device or treatment which is usually not covered by the insurer, you may be able to appeal the case. Working closely with your provider(s) is advised in these instances.
1. Off-label Drug Use
Off-label drug use refers to the use of medication for a purpose that is not approved by the U.S. Food and Drug Administration (FDA) or similar authority. This can include using a drug to treat a condition or symptoms different from what it was originally approved for, using a different dosage of that drug or using it for a different patient population than the intended one. Health insurance companies may not cover off-label drug use unless there is documentation from your doctor about why it was chosen for your condition.
2. Brand New Technology
It’s not so much that health insurance will not cover prescriptions and devices that rely on brand new technology, just that it takes some time to approve the added cost. Insurance companies typically require medical treatments and technologies to have a proven track record of safety and effectiveness before they provide coverage. For instance, most insurers offer coverage CPAP machines for sleep apnea as well the newer, surgically implanted device, Inspire, for sleep apnea.
3. Adult Dental Services
Dental services are costly and require a separate dental insurance plan, except in the case of some Medicare Advantage plans, which include dental services. Note that there is a difference between dental and oral surgery. Dental surgery, like an extraction, would be covered by dental insurance. Oral surgery, however, is covered by medical insurance. Oral surgery can include the removal of diseased or impacted teeth, dental implants, tumor removals and other medical issues. If you can’t afford a dental plan, consider a discount dental plan or sliding-scale dental clinic.
4. Vision Services
Like dental, vision is usually separate from health insurance, except in certain cases. Optometrists, who check your vision and prescribe glasses, are usually covered by vision insurance while ophthalmologists, who perform surgery and prescribe medication, are covered by health insurance. Vision insurance typically covers routine eye exams, prescription eyeglasses, contact lenses, and may provide discounts on corrective surgeries like LASIK.
5. Hearing Aids
While some Medicare Advantage plans cover hearing aids and hearing services, regular Medicare and private health insurance plans do not. The Hearing Loss Association of America lists various assistance programs for hearing aids according to each state. AARP offers a hearing care program for its members. Veterans Services benefits may cover hearing aids, and some hearing aid providers offer payment plans. You can also check your state's Department of Health or Human Services for information on subsidies and financial assistance programs for hearing aids.
6. Uncovered Prescription Drugs
Your physician may need to contact your insurer to ask that they make an exception about a drug they normally do not cover based on medical necessity. If that request is denied, you can file an appeal with your insurance company. Prescription drugs used for purely cosmetic or aesthetic purposes, such as certain dermatological creams or anti-wrinkle treatments, are not covered by insurance, as they are not considered medically necessary. For example, Retin A is covered for acne but not for wrinkle removal.
7. Acupuncture and Other Alternative Therapies
Acupuncture is covered by some health insurance plans and up to limits. For instance, you may be covered for 10 sessions a year and only if it’s related to a medical condition or injury. If your insurer says your therapy is experimental and therefore not covered, you can appeal and try to get it covered.
8. Weight Loss Programs and Weight Loss Surgery
Nutritional counseling, weight loss programs and weight loss surgery (known as bariatric surgery or lap band surgery) are covered by some insurers and not others. You’ll have to check with your insurer or ask for a plan that includes it when comparing rates.
9. Cosmetic Surgery and Beauty Treatments
Insurers will cover plastic surgery only if they believe it’s medically necessary, like after a mastectomy. Botox for migraines will only be covered if your medical provider can provide documentation for why it was used. Upper eyelid surgery is only covered if the eyelid interferes with eyesight. Otherwise, anything considered cosmetic is excluded from traditional health insurance coverage.
10. Infertility Treatment
In some states, insurance companies are legally bound to cover diagnosis and treatment of infertility. See what the laws are in your state regarding infertility treatment coverage. If your state is not listed, IVF and other fertility treatments are not covered.
11. Sterilization Reversal
Most plans don’t cover reversals of sterilization surgery.
12. Private Nursing
Most insurers don’t cover private nursing. Medicare covers some at-home nurse services and home aides if your provider deems it is necessary.
13. Travel Vaccines
Most insurance companies group travel vaccines as elective and nonessential, so they will not cover it.
LASIK is elective and viewed as nonessential, if not cosmetic. Lasik is not covered by health insurance but may be partially covered by vision insurance. You may be covered for Lasik if vision problems arise due to surgery or an injury, or if you aren’t able to wear glasses and contact lenses.