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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.
If your auto insurance policy has comprehensive coverage, then you will be financially compensated for your stolen vehicle.
This Medical Loss Ratio states that when a family or individual buys a medical plan, 80% of every dollar collected and paid to an insurance company MUST pay medical claims/research. So that leaves the insurance company to pay ALL of their expenses with the remaining 20%. .20 cents on the dollar for their employees, buildings, broker costs, etc.
One thing that many people are surprised to see impact their insurance premium, is their marital status. Generally speaking, married people spend less than singletons on their auto insurance, even when all other factors are the same. Simply put, married couples pay less.
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You don’t have to wait until renewal time to make adjustments to your auto policy. Updates can be made as circumstances in our lives change to ensure you have the proper coverage for your needs and budget.
Knowing how to react when they appear can greatly reduce your chances of being involved in an accident. While hitting an animal can be against your natural instincts, swerving to avoid it could cause a worse crash that ends up in major fatalities.
Nevada Health Link has responded to Governor Sisolak’s Emergency Declaration of March 12, 2020 due to the coronavirus, also known as COVID-19. It announced an Exceptional Circumstance Special Enrollment Period. This allows Nevada residents who missed the “Open Enrollment” period to enroll in a qualified health insurance plan through the state-based exchange platform.
The Department of Health and Human Services announced that there will be two new rules created to help improve competitive pricing between hospitals, health insurance issuers, and health plans. The effort is aimed at helping to empower patients when they make their health insurance decisions.