As health care costs continue to climb, an increasing number of companies are passing more costs onto their employees. So even if you have a job that provides health insurance, you need to be a savvy consumer when assessing and selecting a plan.
Just because you’re insured, it doesn’t mean that every procedure and service you might need is covered. Each plan is different, and while most plans cover basic health care services such as regular checkups, there are some services or exclusions that are generally declined by insurance companies. And when that happens, you’ll be responsible for footing the bill.
The best way to learn what your insurance will and will not pay for is to review your policy or visit your insurer’s website for a thorough description of your rights and responsibilities. You can also contact the human resources department of your employer to find out more details about your coverage. Here’s a look at some services and procedures that are generally not covered by insurance companies:
1. Cosmetic Surgery
Cosmetic surgery for beauty purposes is considered an elective procedure and generally not covered by insurance companies. Liposuction, tummy tucks, breast enlargement, nose jobs, face-lifts and some dermatological procedures are considered elective.
“Cosmetic surgery in general is not medically necessary,” says Dave Grant, assistant deputy director for health insurance products for the Illinois Department of Insurance. “It’s not a type of coverage that could save a person’s life.”
There are some exceptions to the rule: If you have a physical deformity, such as a cleft pallet, and the procedure is done for reconstructive purposes, such as after a mastectomy or because of illness or injury, health insurance usually will cover the costs.
In some cases, breast reduction surgery is also covered by insurance if it helps alleviate related health problems such as severe back pain, according to the American Society of Plastic Surgeons. The group’s website also indicates that eyelid surgery, which is nearly always cosmetic and not covered, is generally covered if the patient needs it to improve their vision. In that case, it may be considered reconstructive.
2. Lasik Eye Surger
Vision corrective surgery is typically not covered by insurance plans, but some consumers may purchase separate vision coverage that may pay for this procedure.
3. Infertility Treatments
Infertility treatments are rarely covered by insurance companies. But some employers offer this in their benefits plan. Under new health care reform laws, some states, such as Illinois, mandate group health insurance and HMO policies that cover more than 25 full-time employees. Often these policies must provide coverage for the diagnosis and treatment of infertility, but not necessarily the subsequent treatment.
“Illinois was one of the first to mandate the coverage,” says Mary Peterson, acting supervisor of the life, accident and health unit for the Illinois Department of Insurance. “We are still one of the more generous states… as there’s no dollar maximum limit for the treatments.”
4. New Technology
“New technology that has not yet been proven to work is generally not covered by insurance companies because it could do more harm than good,” Peterson says. “Although, Illinois does have a new law on the books that says if your doctor says this is your last and best chance at survival, you may be able to get coverage for an experimental procedure. It would be considered as an allowable exclusion.”
Insurance also rarely pays for clinical trials, where drugs are being studied or are in development or have not yet been approved by the U.S. Food and Drug Administration. The medical research facility that performs the clinical trial will provide medication to those who take part in testing of a new drug. The National Institutes of Health maintains a public database of clinical trials at ClinicalTrials.gov.
5. Alternative Medicine
While alternative medicine, such as chiropractic services, massage and acupuncture, are generally covered by insurance plans, it is not universally true for all plans. In addition, companies may offer discounts for yoga and meditation, but they are not universally covered in all health plans.
According to the website for the National Center for Complimentary and Alternative Medicine, some employers also allow workers to purchase alternative medicine riders to their standard health insurance plans.
