Whether you are looking to choose a new health insurance policy, enroll in Medicare or are unsure of the details of your current health plan, there are a number of services that you may think are covered, but actually are not. Knowing ahead of time what services you will have to pay for can help you make smart health care decisions.
First, How to Get Coverage
If your employer offers health insurance, you’re usually set. But if you leave your employer or recently found yourself without health insurance (and you’re not Medicare age), here are your options for health insurance coverage:
- COBRA coverage. If you lose your job, COBRA can give you the option to continue your health coverage for up to 36 months. “If you’re really stuck and need some coverage for a few months, this is an option,” says Lori-Ann Rickard, J.D., creator of MyHealthSpin.com and a health care attorney. But, Rickard points out, COBRA can be very costly since you will be responsible for paying for coverage and your employer must employ more than 35 people to offer COBRA.
- Your spouse. “If you have a spouse and he or she is employed, sometimes they can add you to their insurance,” Rickard says.
- Private policies for individuals/families. “There are some private insurance plans created for individuals or families that you can look into,” Rickard says. These are plans created by companies such as Aetna, Blue Cross and Cigna. To research these plans or find out if a company offers plans in your state, visit the insurer’s website.
- Public Exchanges. All states have state-run health care exchanges, or marketplaces, that list plans. The best way to find out is to find a trusted navigator, either online or in person, to help you learn what options are available. A good place to start is with the easy-to-use navigation system at CuidadoDeSalud.gov.
- Health Insurance. “If you can’t do any of the other things mentioned, you’ll want to look into Medicaid, which is administered by the state government,” Rickard says. “There are certain income requirements and state-specific requirements for Medicaid, so it’s not available to everyone.”
A word about enrollment
Each year there is an open enrollment period, when people can compare health insurance policies and choose or change health plans. This year’s open enrollment period runs from November 1 through January 31. However, if you lose your job or your current insurance ends for any reason, special enrollment periods are available.
“However, special enrollment periods end 60 days after the triggering event, so it’s important to act early,” says health insurance expert Louise Norris, a contributor toHealthinsurance.org and Medicareresources.org. For Medicare, enrollment occurs within a seven-month period around your 65th birthday.
If you’re looking to change Medicare plans, Medicare’s open enrollment period runs from Oct. 15 to Dec. 7.
What insurance does it cover?
Prior to the Affordable Care Act (ACA), health insurance providers could independently decide which services to cover and which not to cover. The ACA created a standardized set of 10 essential benefits that all individual and small group plans (available to companies employing fewer than 50 employees) must cover. These 10 essential benefits cover many health care needs, such as doctor visits and hospitalization, but health plans are not required to cover other services.
“In the large group market, the rules are a little different,” Norris says. “Preventive care must be covered, and employers with 50 or more employees must offer health insurance that provides ‘minimum value,’ meaning the plan must cover at least 60 percent of the cost of covered services for the average population.” Large groups are not required to offer all ten essential benefits, although most do. All Medicare and Medicaid policies as of 2014 must offer all 10 essential benefits.
Keep in mind that just because a service is not among the ten essential elements doesn’t mean your insurance company won’t cover it. That’s why it’s smart to make a list of essential services for yourself, then call your insurance company and ask if the services are covered in whole or in part.
What is not covered
1. Travel Vaccinations: Travel vaccinations are different from general health vaccinations. If you need a tetanus or flu shot as part of your health maintenance, your insurance will generally cover them, as they are considered necessary preventive care. But if you are traveling abroad and need, say, a typhoid or yellow fever vaccine, most if not all insurance plans, including Medicare, do not cover these types of vaccines. Insurance covers things that are considered “medically necessary,” and “someone somewhere decided that travel vaccines are not medically necessary,” Rickard says. “I guess the idea is that you don’t really have to take the trip.”
2. Acupuncture and other alternative therapies – Sometimes alternative therapies are covered, but it depends on your plan and your state.
“In the under-65 market, individual health insurance is not specifically required to cover massage therapy, acupuncture or chiropractic care,” Norris says. “But depending on how a state defines its essential health benefits package, these services may be covered.” For example, chiropractic care may fall under the essential health benefits category of rehabilitative care or outpatient care, Norris notes, meaning that a person who suffers a back injury in an accident and is receiving treatment for the accident from a chiropractor would likely be covered. But a person who visits the chiropractor every two weeks because it makes him or her feel better or to prevent back problems would probably not be covered. Also know that in most states that cover chiropractic care, there are limits on the number of visits covered (usually between 10 and 30 visits per year).
Original Medicare does not cover acupuncture, but it does cover medically necessary chiropractic care. Medicare Advantage plans, which are an alternative to Original Medicare, may cover acupuncture and more extensive chiropractic care, but it varies from plan to plan.
3. Cosmetic surgery: again, this all depends on what is considered “medically necessary”. If you are looking to have a nose job or facelift because you think you will look better, insurance will not cover it. However, if you need reconstructive breast surgery after a mastectomy, it would be considered medically necessary and covered.
4. Nursing home care: “Regular nursing home care is not covered by commercial health insurance plans or Medicare, although it is covered by Medicaid,” says Norris. If you want coverage for nursing home care, “that’s what long-term care insurance covers.” What is covered is short-term care in a skilled nursing facility. So if you fall and fracture your hip and have surgery, you may need assistance in a rehabilitation facility or skilled nursing facility to help you with your recovery. Generally, those costs would be covered, since they are short-term and the result of a medical incident. However, says Norris, “Commercial plans may impose limits on the length of time they will cover in a skilled nursing facility.”
For Medicare to cover skilled nursing, the requirement is that the person must have had a hospital stay of at least three days (not counting days that are considered observation rather than inpatient) prior to the skilled nursing facility stay. And the skilled nursing facility stay must be intended to help the patient recover from an illness or injury, rather than a chronic condition.
5. Dental, vision and hearing: Most health insurance plans do not include dental, vision or hearing services. If you want coverage, you will need to purchase a separate plan that includes one or sometimes all of these services. But before you buy a plan, know that they are not regulated by the ACA, which means they do not have specific requirements in terms of what must be covered. They also generally don’t have limits on out-of-pocket costs. “Honestly, if you look at the cost of a dental cleaning that’s $110 twice a year where I live, the cost of paying the monthly fee for dental insurance is much more than that, so the insurance is not worth it.” says Rickard. If you are eligible for Medicare, Original Medicare does not cover dental, vision or hearing services, but there are some Medicare Advantage plans that do.
6. Weight-loss surgery: Medicare and most Medicaid programs cover bariatric surgery, but there is no federal requirement that private plans cover it. However, 23 states currently require some type of coverage for bariatric surgery as part of their essential health benefits package. That could mean that some weight loss procedures are covered and others are not. And there’s no guarantee that coverage will pay for all costs associated with surgery. If bariatric surgery is something you’re interested in, it’s best to compare plans and look at the fine print of exactly what’s covered.
7. Preventive testing: this one is a bit murky as many tests are covered by insurance, while others are not. Mammograms, cholesterol screenings and colonoscopies are covered, for example, while prostate-specific antigen (PSA) tests are not.
There are three government agencies that determine what is considered “recommended preventive care,” Norris says. “If there is not enough evidence to recommend specific preventive care, it is not included in the list of care that is fully covered by health insurance companies,
“That’s why PSA testing is not included in the list of covered preventive care, for example. Another example of a preventive screening test that should not be covered is vitamin D testing, as the U.S. Preventive Services Task Force. (one of the thirteen guideline-setting agencies) considers the evidence of its value to be insufficient at this time.”
For a list of covered preventive services for all adults, click here. For a list of covered preventive services for women, click here.
8. All medications: The good news is that prescription drugs are included in the list of 10 essential health benefits, which means the drugs are covered by insurance. However, as Rickard says, “the devil is in the details.”
Health insurers have lists of covered drugs called formularies, and insurers have a lot of flexibility in creating their formularies. According to Norris, “they have to cover at least the greater of: One drug in each United States Pharmacopeia (USP) category and class, or the same number of drugs in each USP category and class as the state’s essential health benefit benchmark plan.
“In other words, insurance companies do not have to cover all drugs, but can choose and cover one drug in each class. Generic drugs are also more likely to be covered than brand-name drugs. The best thing to do is to make a list of all the drugs you take and then research which drugs the different plans cover. Also keep in mind that each formulary has drug tiers. The higher the tier, the higher the out-of-pocket cost.
If you have Original Medicare, you must purchase a prescription drug plan (Part D) to cover your drug expenses. Some Medicare Advantage plans include prescription drug coverage.