Common Health Insurance Exclusions

Since the passage of ACA, health insurers in the US have been required to cover preexisting conditions, prenatal care, and a number of other "essential benefits". And this might give the impression to some that, basically, everything is covered and has to be by law. But that is not at all the case.

​Health insurance policies still include various exclusions that consumers need to be aware of when shopping for new insurance. The last thing you need is the surprise of a specific care not being included in the plan you chose.

What Is Typically Excluded From Coverage?
If you are thinking of switching health insurance or looking for a new policy, be sure to ask a health insurance agent to explain to you potential policy exclusions. Not all insurers have the same exclusions, but here are the most common ones:

• Chronic (long term) care for the elderly or others with chronic health conditions.
• Most dental procedures and eye exams, except for children.
• Weight loss programs and weight loss surgeries.
• Regular foot care and treatment.
• Private nursing services.
• Cosmetic surgery and any procedures not deemed "medically necessary."
• Infertility treatments.

Considering that you have to pay all non-covered (excluded) items out of pocket in full (and maybe upfront), it pays to choose a policy that covers something you may use when other policies don't. Adding dental insurance and other supplemental insurance can also help to plug in the gaps. Finally, note that taxes on even covered medical care are excluded from all insurance policies.

Other Limits On Health Insurance Coverage
Even when you know what is and is not covered by your policy, there are still other limitations to what it will pay. You need to be aware of these ahead of time and calculate how much you would likely pay out of pocket in a typical year (as compared to your premiums) to decipher what is the best overall deal for you and your family.

All health insurance is going to have cost-sharing of some kind. You will have copayments, coinsurance, and (usually) a deductible. There may also be an annual or lifetime coverage cap or caps specific to particular kinds of care. On the flip side, there may be out of pocket limits protecting you from paying excessive amounts in a single year. Out-of-pocket limits can also be limited to particular coverage areas (such as prescription drugs); so it would be worth investing into a health insurance agent to help read the fine print.

For major medical procedures, you may want to get prior authorization to make sure the insurer is going to cover it and not leave you paying in full out-of-pocket.

No matter how good the coverage is when it applies, it will do you no good on those costs that are excluded. So be sure to scan each potential insurer's exclusions list to see if it contains anything you think you will need.

To learn more about how health insurance exclusions work, or to discuss your options with an experienced broker, contact Summerlin Benefits Consulting today!