Health Care Gray Areas: How to Know What Insurance Covers

Daryl Paranada

By , Staff Writer
Posted on Wed Mar 5, 2014, Last Updated on Wed Mar 5, 2014

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Health Care Gray Areas: How to Know What Insurance Covers

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Do you know what procedures or services your health plan covers? Before you receive any type of health care treatment, it’s always a good idea to take a look at your plan and see what type of coverage your insurer provides. The last thing you want is to receive a surprisingly high medical bill for getting a test or procedure your provider doesn’t cover.

That said, the Affordable Care Act has made it easier to determine which types of services and treatments are offered. The health care law ensures that health plans offered in the individual and small group markets — both inside and outside of the health insurance marketplace — offer a comprehensive package of items and services deemed essential health benefits.

These essential health benefits include at least the following services and items:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (such as for surgery)
  • Maternity and newborn care (before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services

But what about gray areas such as cosmetic surgery or infertility treatments? Does the Affordable Care Act mandate that insurance providers cover those services? The key question about coverage for many of these procedures or services is whether they are “medically necessary.” The best thing you can do if you have a question about coverage is to ask your insurer. Your specific case or ailment might be covered, but you won’t know unless you ask.

Here are a few gray areas of coverage that you might want to be aware of:

Autism

More people than ever before are being diagnosed with Autism Spectrum Disorders. According to the Centers for Disease Control and Prevention, about one in 88 children has been identified with ASDs. But do insurers provide coverage for the treatment of autism? Some have to. At least 31 states require insurers to provide coverage for the treatment of autism, according to the National Conference of State Legislators. It’s best to check with your insurer to find out what is covered. Learn more about how the Affordable Care Act might affect individuals with autism and their families.

Cosmetic surgery

One of the essential health benefits covered under Obamacare is “rehabilitative and habilitative services and devices,” but that coverage has more to do with hip replacements than face lifts. Plastic or cosmetic work is a type of elective rather than emergency surgery. Generally, it is not covered by insurance — unless it is considered reconstructive. For instance, if you get breast reconstruction surgery after having a mastectomy or if you choose to repair your skin after being in a fire. In some cases, part of your surgery may be covered by insurance if you’re getting work done for a legitimate medical concern. If you’re having surgery just to improve or enhance your appearance, don’t count on getting coverage. But as always, it’s best to ask.

Infertility treatments

More than 7 million women between the ages of 15-44 in the U.S. have used infertility services, research from the CDC shows. Infertility treatments have helped many couples have children, but they’re not cheap. RESOLVE, the National Infertility Association, says the average cost of an in vitro fertilization cycle costs $8,158. But will your insurance cover treatments? Some states require insurance companies to cover infertility treatments. Check to see what your state’s laws are. States with an IVF mandates include Arkansas, Connecticut, Hawaii, Illinois, Massachusetts, Maryland, New Jersey, and Rhode Island. If you live in one of those states, research what your insurance plan is legally required to cover. If you don’t live in a state that covers infertility, check to see if your employer covers infertility treatments.

Maternity

Once a health insurance gray area, the Affordable Care Act has helped clear what is legally required of insurers when it comes to maternity care. Before the health insurance law, insurers could turn you down if you applied for a plan while pregnant because they considered pregnancy to be a preexisting condition. Under the new health insurance law, you can’t be denied or charged more coverage if you’re pregnant. Moreover, under the health care law, pregnant women and new moms will receive access to a host of recommended preventive services, including gestational diabetes screening, lactation support, and contraception.

Obesity

The CDC says more than one-third of U.S. adults are obese. In 2008, the estimated annual medical cost in the U.S. for obesity totaled $147 billion. So what are insurers legally obligated to cover? The Affordable Care Act requires most insurers to tackle obesity, at least in its initial stages. All insurers have to cover screening and counseling for obesity under the Affordable Care Act’s preventive services benefit — with no patient cost-sharing. But when it comes to treatment, obesity is largely being handled at the state level. Some states have obesity treatments listed under their essential health benefits, but not all do. Check to see what your state mandates for treatment coverage. Also, note that some grandfathered insurance plans don’t have to cover obesity treatment if their overall coverage since 2010 hasn’t changed.

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