What Is An Exclusion In Health Insurance?

In health insurance, an exclusion is a medical procedure or treatment that the health insurance company does not cover. This may include specific medications, surgeries or therapies that are specifically omitted from your policy. Exclusions vary from plan to plan, meaning that even if your friend’s health insurance covered a service, yours may not.

It’s more difficult for insurance companies to exclude many medical procedures if the insurance is considered a “qualified health plan” and meets the ACA (Obamacare) rules and standards. Most anything “medically necessary” should be covered. Not all medications will be, you’ll need to look at the health insurance plans “formulary” which is a list of medications that they will cover.

What Are the Most Common Health Care Exclusions?

While exclusions vary considerably across plans, there are some that are consistent regardless of the health insurance provider. A health insurance agent can help you review your coverage to determine the exclusions that apply to you.

Hospital Stays

Hospital fees can be notoriously high. While you expect to pay for services such as diagnostic screenings, physical therapy, and skilled nursing services, you may not expect to see your bill ran up by non-medical nickel-and-dime charges. For example, if you use the television in your hospital room, you may have to pay for that luxury out of pocket, as most health insurance companies exclude coverage for it. The same goes for bandages, extra pillows and even use of the in-room telephone.

Pre-Existing Conditions

Thanks to the Affordable Care Act, health insurance companies can no longer deny coverage for pre-existing conditions. Also, very good news, there are no longer waiting periods for covered services and treatment related to the medical condition. Pre-existing conditions must be covered the first day your policy is effective without lifetime or yearly limits on coverages for the “essential 10 healthcare benefits”.

Elective Surgeries

Elective surgeries such as nose jobs and face lifts are usually not covered by health insurance. In some cases, if surgery is needed to fix an injury, health insurance coverage may apply. But “vanity” surgeries will, for the most part, not be covered. Hair loss after cancer treatments most likely will be covered. Breast augmentation after cancer would be covered. But just wanting hair transplants due to familial hair loss won’t be covered and getting breast implants to enhance your self-confidence will not be covered. Having gastric bypass will not be covered unless you meet the medical requirements to deem it medically necessary. So being medically necessary is one factor that plays the biggest role. Another would be to restore you back to pre-harm, pre-injury or pre-disease status.

Dental and Vision Services

Dental and vision services such as teeth cleanings, cavity fillings and eye exams are not covered under health insurance for adults. The ability to buy your own dental and vision plan is open to enrolling into year-round. You are not limited to certain times of the year to buy your own private dental and vision plan. If you work for an employer that offers these benefits, you’ll need to make sure you opt in during their “open enrollment” period at work.​

How to Avoid Surprise Medical Bills

There are a few steps you can take to avoid high out-of-pocket medical costs.

Look beyond the short list of exclusions in your policy handbook
The exclusions can change, so make sure you have an up-to-date list
Before setting up a payment plan for hospital services, get an itemized bill
Research your state’s rules regarding services that can be excluded from your plan​
Call your health insurance company to find out if a new treatment or procedure is covered under your policy

Find Health Insurance Coverage with Nevada Insurance Enrollment

Understanding health insurance coverage can be challenging, but Nevada Insurance Enrollment is here to help. We have experienced health insurance agents who help you review and understand your coverage options to avoid high future medical costs.