Some health insurance plans do not provide coverage for common illnesses or conditions.
It is very important to understand your health insurance coverage. Many health plan participants pay for insurance without thorough knowledge of what the policy will pay for in the event of a claim or medical emergency. Some insurance policies provide comprehensive coverage while others provide little or no coverage for care that is essential to maintain a healthy lifestyle.
Managed Care Plans
Managed care health insurance provide plan participants access to a network of service providers for a discounted rate. Common managed care providers include Health Maintenance Organizations and Preferred Provider Organizations. Plan participants choose their health care professional and medical facility, and receive lower costs by choosing professionals within the specified network.
Managed care plans provide a variety of services. They provide care for doctor and hospital services, including inpatient and outpatient surgery. They provide treatments for illnesses and diagnostic services, such as X-rays and mammograms. Preventative, emergency and rehabilitation care is also included in these plans.
While they do provide comprehensive levels of care, managed care plans have certain restrictions. For example, managed care plans do not provide coverage for alternative medical treatments, such as acupuncture, hypnotherapy or naturopathic medicine. Also, coverage for cosmetic procedures are excluded. Coverage for medical supplies, such as batteries or blood pressure monitors, are not included. Nor is infertility or genetic testing procedures. Individuals who require specialized tests or care must pay out of pocket for the related medical expenses.
Limited Indemnity Plans
Indemnity health insurance plans provide limited health benefits in comparison to managed care plans. These types of plans provide only basic and essential care. They generally do not offer coverage for prescription drugs, maternity or preventative care, or for treatments such as chemotherapy. For a set price, plan participants have the option to choose a health care provider. The plan participant or the health care provider is reimbursed for services rendered. Indemnity plans often impose restrictions or prior authorization on hospital care or other high cost services.
Pre-existing Conditions
Most individual health insurance plans do not provide coverage for pre-existing conditions. A pre-existing condition is an illness that affected the individual before receiving coverage. For example, if a plan participant was diagnosed with or treated for cancer, diabetes or asthma before receiving health insurance coverage, the participant is said to have a pre-existing condition. Most health insurance policies cover the individual for other health matters but exclude coverage specifically for the chronic health condition. Pregnancy is a health condition that is not automatically covered by an insurance provider but may be added for an additional premium with some insurance plans. General gynecological care, such as pap tests and pelvic exams, require an additional premium as well.
Prevention/Solution
The best way to ensure that you and your family are covered for your overall health care needs is to become informed about your plans inclusions and exclusions. Most policies contain complex insurance jargon that is difficult to understand. Solicit the help of a licensed, experienced health insurance professional to translate the insurance terms and explain to you precisely what you are paying for. Although health insurance premiums are relatively expensive, make coverage decisions based on the needs of your family and not how much the insurance costs. This will ensure you have the proper coverage when the time comes to file a claim.
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