When you have to have major surgery, it’s often the case that your health insurance won’t pay out the money you need to cover your medical bills. This can be devastating to those who are already dealing with serious illnesses and injuries, but there are ways to work around this unfortunate reality so that you can get the financial support you need from your insurer. We’ll look at why health insurance doesn’t pay and what to do about it later in this article. For now, let’s start with how health insurance works and why having one is so important.
When health insurance won’t cover treatments
There are a number of reasons why your insurance may not cover certain treatments or medications. Most health insurance policies today don’t include a prescription benefit and may require pre-approval for some prescriptions. Patients with deductibles may have to pay for treatment, testing, or medications out of pocket until they meet their deductible. A high-deductible health plan (HDHP) will have lower premiums than other plans but has a higher deductible, which means you must pay more before your insurance coverage kicks in. You may also have co-pays if you get care at an in-network provider who accepts your particular plan or if you fill a prescription at an in-network pharmacy.
When health insurance won’t cover diagnoses
When you see a doctor, there are a number of diagnoses that health insurance plans will not cover. If you develop one of these conditions and it’s being treated, your insurance company won’t pay for treatment unless other criteria are met. Here are some of them
When health insurance claims are denied unfairly
The first place to appeal an insurance claim is with your insurer. If that doesn’t work, go up a level, to your state’s health plan. After exhausting your options with those entities, you can file a complaint with your state department of insurance and also file a complaint with Medicare if it pertains to a claim denied by an HMO or Part D prescription drug coverage (you can find their contact information here).
When you need care, but can’t get it
If you have health insurance, it’s a good idea to ask your doctor or provider office if they are in-network. If they are not, you might have to pay full price up front. Even with insurance, you could be liable for your deductible (in 2016 it was $6,850) and any uncovered medical expenses if your provider isn’t participating with your health plan. The good news is that many doctors will help uninsured patients who can’t afford to pay their bills.
Understanding your health plan benefit statements
If you don’t understand what health insurance is paying for and why it may be time to start asking questions. Most policies today are gatekeeper plans, meaning they require patients to use certain providers. These providers have negotiated discounted fees with insurers. Even though your plan will pay up to a certain amount toward a service or procedure, you might still be responsible for additional charges above that rate—these are called co-insurance fees. When your total fees come out of pocket (rather than from your insurer), it’s called out-of-pocket expenses. Understanding how much you owe for each of these categories can help you make more informed decisions about what care makes sense for you and your family and make financial planning easier.