In general, bills of any kind are met with groans, but unexpected medical bills are undeniably the worst. They have a habit of coming at the worst time and weeks or even months after you’ve seen a doctor or had a procedure. Despite the inconvenience they’re far more common than you would think even when you have health insurance. Unfortunately, not everything is covered by health insurance, which is a bitter pill to swallow considering how expensive it can be.
While we have no control over which services are covered (or how much we have to pay for them), we can understand exactly what the benefits and coverage are. As long as your deductible is met, you generally don’t have to worry about paying for routine exams, surgical procedures, or lab work. However, some procedures are excluded. These are primarily “elective” procedures, such as weight loss surgeries. Unless you are a special case, your chances of having them covered are slim. Below we’ll go over what insurance companies typically cover, what they won’t and how to avoid expected medical bills.
What Most Health Insurance Plans Cover
Typically, depending on the type of plan you have, most health insurance plans cover:
- Maternity and newborn care
- Emergency services
- Preventative services such as:
- Annual check ups
- Routine blood work
- Cancer screenings
- Blood glucose tests
- Blood pressure monitoring
- Blood cholesterol monitoring
The primary differences in these coverages depend on your company and the plan tier you choose. For instance, some of these could require copays or coinsurance.
What Health Plans May Not Cover
Surprisingly, there are a lot of things that are either not covered or are only partially covered by most insurance companies.
Typically, insurance companies will only cover routine vaccinations that are needed in the U.S. Tropical disease vaccines are not covered if you are traveling to other countries. Most health insurance companies see these as not medically necessary.
Even though there are numerous studies that show acupuncture has real medical benefits, health insurance doesn’t agree, since it doesn’t fit into most concepts of western medicine. An acupuncture visit can cost anywhere from $100 and up, out-of-pocket.
Unfortunately, many state health insurance plans do not cover in vitro fertilization (IVF). Whether you’re having trouble getting pregnant or just simply want to go a different route to your pregnancy, the procedure can cost between $10,000 and $20,000. Currently there are only 15 states that have laws making IVF coverage mandatory for health insurance.
In general, health insurance does not cover elective surgeries. Meaning that if the surgery isn’t approved by your physician for medical needs rather than cosmetic reasons it won’t be covered. For instance, if you have large breasts, a breast reduction is only covered if your doctor provides sufficient evidence that your breasts are causing health problems. Make sure you talk to your health insurance provider and doctor to avoid unexpected cosmetic surgery bills.
Dental and vision
This one can be surprising, but most health plans will not cover dental or vision care. There are however add-ons that you can purchase that are basically extra coverage specifically for these types of care. Additionally, things like LASIK (laser eye surgery) are seen as elective and not medically necessary.
Just like with breast reductions, unless your weight is causing severe health conditions your health plan will most likely not cover it. There is no federal law requiring health plans anywhere to cover these at all. Even if your doctor deems it medically necessary it can be very difficult to get these procedures covered.
This is another surprising one, you’d think that hearing aids would be automatically considered medically necessary. And many people agree with you, this has been an ongoing argument in the United States for years. But as it stands most plans won’t cover hearing aids even though they’ll cover hearing exams. Currently only 4 states require hearing aids to be covered.
If you are hurt outside of your plan’s coverage area you’re probably out of luck. Your health insurance will most likely not cover out-of-network doctors unless it’s an emergency. And even then it’s tricky. However, there are plan types that do have some out-of-network coverage such as Preferred Provider Organizations (PPOs). They cover these doctors much less than their network providers but there is still some coverage there.
How To Avoid Unexpected Medical Bills
The good news is that you can avoid many unexpected medical bills by taking a few extra precautions before your appointments. Here are some simple strategies recommended by patient advocates and insurance professionals.
1.Read, Read, Read!
Every January, your health insurance company will mail or email you a packet containing all the information about your plan. Although the language can be a bit jargony and difficult to read, it’s in your best interest to read through this packet thoroughly. You can’t just assume specific procedures and services are covered. That is how you end up with unexpected costs. Instead you need to read the fine print to gain an understanding of what your plan’s specific benefits and limitations are.
We recommend highlighting important parts you think can or will pertain to you. Take note of your plan’s deductible, this is the amount you have to pay during your coverage period before your plan will begin paying for medical expenses. For example if you have a $500 deductible, you are responsible for paying for your medical costs until you reach that amount. After that your plan will pay for covered services in full for the remainder of the year.
You’ll also want to note which services are fully covered. For certain preventive services, such as a flu shot, annual physical, etc, you will only have to pay a copay with the remainder being covered by your plan. These things are essentially free so you’ll want to take advantage of them.
Insurance companies establish a network of covered healthcare providers, labs, and hospitals. Outside of the coverage area, you will face a huge financial burden. This is because your insurance company negotiates rates with their participating providers, giving you services for a cheaper rate. In general, health insurance plans do not have to cover care from out-of-network providers. However, there are a few exceptions. All plans legally have to cover out-of-network services if it’s an emergency.
To stay on the safe side, always make sure your provider is in your network before your appointment or any procedure. Prior to something as major as surgery you will definitely want to double check what your plan will cover. Make sure the facility, anesthesiologist, and equipment are all covered under your plan. That way you don’t end up with any unexpected costs.
Even if you know your doctor or facility is in-network, always ask about coverage. If your doctor wants to perform a blood test, an EKG, or any other procedure or test during your appointment, ask if it’s covered before you consent. If the doctor is unsure, you can request the procedure’s Current Procedural Terminology (CPT) code and then call your insurance company to find out if it’s covered. This is helpful because your insurance may cover one type of mammogram for instance, but not another. Having this CPT code will make it easy for you to get a direct answer quickly to avoid unexpected bills.
Comparing costs is a must! If your doctor sends blood work out to multiple labs, or if you have several pharmacy options near your home check the costs. One lab or pharmacy may be cheaper than another.
By now it’s obvious the best way to avoid unexpected medical bills is to do your homework ahead of time. This is especially true when it comes to procedures. Most health insurance plans will require you to have pre approval for surgical procedures. If you don’t get the approval ahead of time you’ll face penalties or having to foot the entire bill yourself.
6.Expect The Unexpected
In the best-case scenario, you won’t have any medical emergencies, but plan ahead just in case. At the moment you won’t have time to call your insurer and ask which hospitals are covered. So, in your spare time, look up which hospitals near you are covered. Spend some time looking over your ambulance coverage as well. According to a study published in JAMA Internal Medicine, 85% of ambulance services end in out-of-network charges. In an emergency the most important thing is making sure you get the necessary care. We know you might not be in a situation where you can stop and ask if the ambulance ride is covered. However, in a non-life-threatening situation take a moment and ask if there’s a way to get an ambulance service that your insurance company will cover.
A simple phone call can provide you with a lot of answers to important questions. Such as whether or not a procedure is covered, if the physician is in-network, and which lab is preferred. But even after you get your answers, take one more step and get it in writing. Always request any information you get to also be sent in writing, regardless if it is a conversation with an advocate, the billing department, or a patient representative. This way you have everything you need in case you need to dispute any questionable charges.
The Final Step Work With EZ
All of that homework is a lot right? Well, here at EZ we can minimize all of this for you. By working with one of our highly trained licensed agents you can get all the answers you need in one place. They can compare all of your plans to make sure you get the best coverage for you as well as translate all the legal jargon in your insurance information packet from step 1. And they do it all for free! No hassle, no obligations. Enter your zip code into the bar below for free instant quotes to get started or call one of our agents directly at 877-670-3557.