Your Health Insurance May Not Cover Everything You Expect

Understanding your health insurance coverage can be a big challenge. This is especially true if your plan has special rules about only covering care from in-network providers or having to seek certain treatments for a condition before more drastic measures, such as surgery, can be taken.

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As a patient, you have limited control over what tests and procedures your doctor orders, where you obtain those services, and what you ultimately end up paying. Even if you do your research and ask how much your health insurance policy will pay for a particular service, health insurance companies have contracts with medical professionals and generally will not discuss their pricing between themselves and the providers. 

Things Potentially NOT Covered By Your Health Insurance Company

In many cases, neither your health provider nor your health insurance company can give any insight into how much you will pay. It is not unusual for a doctor to order a service, the patient to follow their doctor’s orders, and the health insurance company to pay only a small portion of the cost. The health insurance company has pre-negotiated, contracted prices and pays the contracted amount to the provider.

To be fair, in recent years, health insurance companies have made strides towards transparency. If you have an ACA-compliant plan, there are many services that your health insurance is legally required to cover, taking some of the guesswork out of budgeting for health expenses.

Reading your health insurance plan’s coverage paperwork can help you make sure that a service or medication that you are getting is covered. If you have any questions about your coverage, call your health insurance company (usually the member services phone number on the back of your insurance card), or talk to your health insurance agent.

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Services Not Covered by Health Insurance

  • Cosmetic procedures. Elective services that are meant to enhance your appearance, such as certain dermatological procedures and plastic surgery, are usually not covered.
  • Fertility treatments. While rules vary from one state to another, most health insurance companies have very limited coverage for fertility treatments. In Nevada, health insurance companies may cover up to 6 cycles of artificial insemination per lifetime, with prior authorization approval. Check your plan’s “Evidence of Insurance” for details.
  • Off-label prescriptions. Medications are tested and approved for treating specific disorders or illnesses. In higher or lower dosages, however, they may be effective in treating other conditions. If a medication is being used to treat a condition that is not listed on its label, then the health insurance company may not cover it.
  • New technology or treatments. While there have been significant technological advances in screening and treating certain conditions, health insurance companies tend to be slow to catch up. Unless medical companies can prove that a new technology dramatically improves patients’ likelihood of surviving an illness, the health insurance company is unlikely to cover it.

Getting Help with Nevada Insurance Enrollment

It is hard to budget for health expenses when you do not know what your cost-sharing responsibility will be. At Nevada Insurance Enrollment, our health insurance agents can help you review your policy or find reliable health coverage. We can also help you understand the claims handling process and dispute denied claims.

Related Articles:

Important Public Service Announcement! Fake Health Insurance Scams

Understanding Co-Insurance With A Health Plan

Getting to Know Your New Health Insurance Plan

Fertility Coverage by Health Insurance Companies. Covered? Or not?


Read More: Health Insurance in Las Vegas, Nevada


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