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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.
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 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.
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 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 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.
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
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.
This also applies to damage that occurs after the accident. While you may consider the damage from the accident and the damage from the tow truck to be all one incident, your insurer will view it differently.
If your friend was hit by an insured driver, the process will be simple enough. The at-fault driver will file a claim with their insurance company, who will pay to get your vehicle back to pre-accident condition. If the collision was bad enough to cause an injury, the at-fault driver’s auto insurance could also cover medical bills, lost wages and any other expenses associated with the accident.
Generally speaking, anyone who lives with you that has a drivers license – whether they’re a member of your family or not – is considered by your insurer to be a member of your household. College students away from home without a vehicle aren’t required to be on a policy, and could be a “permissive” driver.
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A high-risk driver is one who is more likely to file a claim. To determine your riskiness, your auto insurance company uses a complex algorithm that weighs in a variety of factors to come up with your auto insurance score.
Telemedicine puts healthcare within reach of those who would otherwise have a difficult time visiting a doctor. If you have a severe sinus infection, the last thing you want to do is spend the afternoon in the doctor’s office.
Do you have car damage that needs to be repaired or parts that need to be replaced? You may assume that the repairs will be done using OEM parts, which means “Original Equipment Manufacturer”, but this isn’t always the case so make sure to review the coverages you have in your auto insurance policy.
Gap insurance is optional auto insurance coverage that covers the difference between the actual cash value (ACV) and the amount owed on the loan of your car if your car is totaled or stolen. Standard auto insurance covers the current depreciated value of your car.