How can you be sure your health insurance covers the treatment you need? Familiarize yourself with your policy, understand your options, and talk to your healthcare provider.
Healthcare providers look at your condition from a medical perspective, not from an underwriting perspective. Because they see patients from a variety of insurance companies, they often don't know as much about the coverage of a particular company or plan as patients do (or should).
Insurance policies are geared toward a broad population, so covered items are based on standard medical procedures for the average patient. Patients, though, have more alternatives—and more successes—in negotiating health care costs and benefits than many realize.
This article will explain the basic coverage rules that health plans must follow, as well as next steps if you find out that your health plan does not cover a service you need.
The Affordable Care Act's Effect on Coverage
The Affordable Care Act, enacted in 2010 (but mostly implemented in 2014) made sweeping changes to the regulations that pertain to health insurance coverage, especially in the individual and small group markets.
Under the new rules, health plans cannot exclude pre-existing conditions or apply pre-existing condition waiting periods (note that this rule does not apply to grandmothered or grandfathered individual market plans—the kind you buy on your own, as opposed to obtaining from an employer—but nobody has been able to enroll in a grandfathered individual market plan since March 2010, or in a grandmothered individual market plan since the end of 2013).2
So if you're enrolling in your employer's plan or purchasing a new plan in the individual market, you no longer need to worry that you'll have an exclusion or waiting period for your pre-existing condition.
In addition, all non-grandfathered plans must cover a comprehensive (but specific) list of preventive care with no cost-sharing (i.e., you don't have to pay anything other than your premiums), and all non-grandfathered, non-grandmothered individual and small group plans must also cover the ACA's essential health benefits with no dollar limit on the coverage.
All plans, including exempt plans, are prohibited from applying lifetime benefit caps to essential medical services. Large group plans are not required to cover mandatory health insurance. Neither do the individual and small group plans for grandpa/grandma. cap.
However, there is no one-size-fits-all policy. The insurance company has still denied the pre-approval request, and the claims are still denied. Ultimately, the onus is on each of us to make sure we understand what our policies cover, what we don't cover, and how to appeal to insurance companies if they don't cover something.
Also, it is important to understand that even if the service is "eligible", you may have to pay the full price yourself (after discounts negotiated by the network). This is the case, for example, if a deductible applies and you have not met the deductible at the beginning of the year.
What to do if a procedure or test is not covered
Ask for alternatives:
Are similar tests or treatments covered by insurance as effective as those that are not?
Talk to your healthcare provider's office.
If you have to pay out-of-pocket because your insurance company does not cover the procedure, talk to your health care provider's office to see if you can get a discount. It is better to consult the office manager or his social worker instead. Try talking to someone in person instead of over the phone. Don't say no in the first round.
Complaint to Health Insurance Company:
Ask your healthcare provider about recommended practice rules and research your insurance company's appeals process. If your health insurance plan is ineligible (i.e. effective after March 23, 2010), the Affordable Care Act requires you to comply with new rules regarding internal and external review processes.
Contact your state insurance representative. If your health insurance plan is not self-insured, the Insurance Commissioner is responsible for regulation (self-insured plans, which cover most large group policies, are instead federally regulated). They can let you know if your health plan may violate certain rules. Here you can find contact details for your state's insurance department.
Clinical trial research:
If you are a candidate for a clinical trial, your sponsor may pay for many tests, procedures, prescriptions, and visits to health care providers. Insurance companies may refuse to pay for the clinical trial itself, but they must not discriminate against you for participating in the care) should still be covered.
These requirements are part of the Affordable Care Act. Before 2014, when the ACA changed its rules, many state insurers could deny coverage while a patient was in a clinical trial. Thanks to ACA, this is no longer allowed.
Get a Second Opinion:
Another healthcare provider may suggest alternative treatments or check the advice of your primary healthcare provider. Many insurance companies will cover the cost of a second opinion but check to see if there are any special procedures to follow.
Your healthcare provider, trusted friend or relative, university hospital, or medical association can provide you with the name of a healthcare professional.
Suggested payment plan:
If treatment is essential and not covered by insurance, work with your healthcare provider's office to ask them to pay your bills over a period of time.
Most health plans cover most medical services that members need. However, doctors may recommend non-covered services, which can be difficult for patients. Fortunately, complaints procedures are available for patients and their doctors, and there may be adequate alternative medical treatments covered by health insurance.