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Understanding your health insurance is important for the health of your body and your wallet. For some basics on health insurance and the difference between in network and out of network providers, check out the article Know Your Insurance.
For help understanding the in's and out's of what’s covered by insurance, I turned to Dr. Archelle Georgiou, a health care executive and former Chief Medical Officer of UnitedHealthcare.
Her first advice? Read the Exclusions section.
Your health insurance policy is a contract between you and your insurance company. The exclusions listed in the policy are the services that will not be paid for by the insurance company.
Exclusions are a common feature in many types of contracts. When you purchase an insurance policy, you agree to accept all parts of the contract, including the exclusions. Keep in mind that if the exclusions were included in the policy, the price of your policy would be much higher.
Some exclusions are for specific procedures like bariatric surgery, artificial insemination, or acupuncture. One of the most common exclusions is for procedures that "are not medically necessary."
This means that if a surgery is required for well-documented medical reasons, it is likely to be covered by your insurance.
However, a surgery or procedure that is optional -- simply because it is your preference or for your convenience or peace of mind -- may not be covered if there are other alternatives that the insurance companies believes are just as effective and less expensive.
Breast reduction and eyelid surgery are common examples of surgeries that are denied because they are not medically necessary.
If you have a specific health condition, you’ll want to make sure the insurance policy you choose does not exclude coverage for that condition. In most cases, coverage for a particular item is included unless it is specifically listed in the exclusions.
If you have specific questions, talk to your HR department or the insurance company representative.
For women, one important consideration is maternity coverage. This is often excluded in basic policies because it is expensive coverage that not everyone needs. But it is a simple matter to choose a policy that does cover pregnancy if you are a woman of child-bearing age.
Just remember, if you are opting in for your employer’s health insurance plan, you may not be able to change your policy during the plan year. So make sure you choose the right policy including maternity care if there is any chance you could get pregnant.
Another topic for consideration is mental health coverage. None of us can anticipate when life events or other factors might lead us to become depressed or in need of counseling or other mental health care.
So consider carefully whether that coverage is important to you when choosing your insurance plan.
Yet another area that commonly causes confusion is "rehabilitative care."
Insurance may cover therapy treatments for an acute condition such as recovering from a broken leg. This condition is considered acute because it is expected to be of short duration and is likely to improve.
The same policy may exclude therapy for a chronic condition such as cerebral palsy because it is a long-term condition that is not expected to improve. Again, you need to read your policy to understand exactly what is covered.
While most facilities confirm in advance that your insurance will pay for a service, the last thing any of us wants is to be caught by surprise by an unexpected medical bill. So no matter what procedure you are considering, check the exclusions section of your coverage document and confirm with the doctor or the facility that they have received prior authorization for the procedure.
If you don't confirm that the procedure is approved, you run the risk that your insurance may deny the claim. This could leave you responsible for the entire bill to your doctor, the facility, and any other providers involved in the claim. A little bit of effort beforehand can save a big headache later on.
Reading any contract or policy can be a challenge. But in the end, you are the one who has the most to gain from understanding what your insurance policy includes and excludes.
If you find something you don’t understand, talk to the Human Resources department at your work, or call the insurance company and ask for help.
Understanding your healthcare insurance can give you a big advantage in being your own health advocate by helping you understand in advance what to expect before the bill arrives.
You can find more tips from Dr. Georgiou here on EmpowHER and check out her blog .
Edited by Jody Smith
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