Trying to understand health insurance coverage in the United States is like trying to untangle a ball of Christmas lights while blindfolded.
But it’s important! If you’re lucky to be among the
87.8 percent of Americans who had health insurance in 2017, then it’s imperative to understand what types of health care costs are covered under your plan and what you will end up paying out of pocket. If not, one unfortunate accident or emergency medical procedure could
bankrupt you financially .
Even if you think that you have a firm grasp on your health insurance fine print, these loopholes in health care coverage may surprise you.
1. Hearing Aids
Hearing loss is the most widespread disabling condition in the U.S., with 48 million Americans suffering some degree of hearing loss, including one out of every three people by age 65. Yet Medicare, the federal safety net program that’s supposed to insure older Americans does not typically cover hearing aids . And neither do most employer and private insurance plans for working Americans, which only cover hearing exams , but not hearing aids. That’s because hearing aids are considered to be elective.
Only four states — Arkansas, Connecticut, New Hampshire and Rhode Island — require private insurance plans to cover hearing aids for both adults and children. Another 18 states have regulations requiring that insurance policies at least pay for kids’ hearing aids, with only Wisconsin covering cochlear implants.
2. Long-term Nursing Home Care
This is another irony of the American health care system, that neither Medicare nor private insurance policies will help pay for nursing homes . Insurance and Medicare might cover short-term stays in skilled nursing facilities for rehabilitation purposes, but it won’t pay for the type of long-term “custodial” care — dressing, bathing, feeding — most of us associate with nursing homes. For that, you need separate long-term care insurance, which is very expensive.
Medicaid is the only program that will pay for a portion of long-term nursing home care, explains
Karen Pollitz , a senior fellow with the Program for the Study of Health Reform and Private Insurance at the Kaiser Family Foundation. But Medicaid, which is designed to help the poorest Americans, requires that you exhaust your savings first.
“You have to spend yourself into poverty Medicaid levels and then the bills will get paid at that point,” says Pollitz.
3. Experimental Therapies
The U.S. is blessed with some of the most innovative and well-funded medical researchers in the world who are constantly developing novel therapies for diseases from cancer to dementia. But unless you’re lucky enough to get selected for a clinical trial — and even luckier not to end up in the placebo group — you will likely have to pay for your own non-FDA approved therapies. In rare cases you and your doctor can petition your insurance provider to cover an experimental therapy if it’s cheaper than the conventional treatment and may result in overall lower costs for the insurance company in the long run.
4. Out-of-network Doctors at In-network Hospitals
Pollitz from the Kaiser Family Foundation says that one of the most common situations that result in unpaid medical bills is when the hospital or outpatient medical clinic is “in network,” but one of the doctors isn’t. Most insurance policies have a cap for how much you pay out of pocket each year with in-network preferred providers, but some of those same policies cover zero percent of out-of-network costs.
So you could have a surgery at an in-network hospital, but the anesthesiologist or the pathologist who runs tests on your tissue may not actually work for the hospital, just in the hospital. If that person is out of your coverage network, your insurance may deny that portion of the claim and charge you the full price of the procedure.
“Unless you’re awake enough to ask doctor before they step in the room, ‘Wait a minute! What plans to you participate in?’ There’s a good chance that you could end up with at least one surprise medical bill,” says Pollitz.
5. Infertility Treatments (IVF)
Just 15 states have laws requiring infertility treatment be included in health insurance, and some of those states specifically exclude in vitro fertilization (IVF) from required coverage. IVF occurs when eggs from the mother are fertilized by sperm in a lab, and then implanted in her uterus. The procedure is expensive ( $12,000-$15,000 a round), and the successful pregnancy rate after just one round is 29 percent. Infertility testing is
usually covered by insurance, as the cost of that is much lower.
Like liposuction (another procedure not usually covered by insurance), LASIK is considered to be elective or cosmetic. LASIK is a laser eye surgery to correct nearsightedness, farsightedness and astigmatism. Since cheaper alternatives to correct vision problems, like glasses or contact lenses exist, that’s what’s covered, assuming you have vision insurance, which is usually an add-on coverage to health insurance. However, most insurance companies have negotiated discounted rates with LASIK providers. And if you can prove that LASIK is necessary for your job performance (for instance, for military service) you might be able to get your insurance company to pay for it.
NOW THAT’S INTERESTING
Every insurance company maintains its own “formulary” or list of drugs that it covers and at what level or “tier.” Higher-tier drugs may technically be covered, but require much higher co-pays at the pharmacy. Insurance companies may often drop name-brand meds from their formularies if they believe that a generic option is just as good or strike up a deal with a competing medication. If your insurance company cuts your favorite prescription, you can either pay out of pocket or ask your physician to petition for an exemption .