 Personal Finance PowerPoint Presentation. What is not covered by Health Insurance. Prepare to get financially fit by practicing personal finance. Remember that insurance is part of our long term comprehensive risk management strategy where we use the adage of measure twice, cut once. We're going to put in a formal plan which looks something like setting our goals, developing a plan to reach them, put our plan in action, review the results and repeat the process periodically. Most of this information is going to be found at Investopedia. What does health insurance not cover, which you can find online. Take a look at the references, resources. Continue your research from there. This was by Christina Zucci, updated March 7th, 2022. What does health care not cover? So we've been discussing different types of insurance, noting that health care often is more complicated than other types of insurances due to the nature of the health insurance industry as well as the laws around the health insurance industry. When we're talking about like property insurance, for example, we might simply be covering against some event that might happen in the future, might have a low probability of happening, something like the house burning down. But if it was to happen, it would be a significant financial burden. So we might want to have insurance against it to cover that kind of event. Same kind of thing could happen with the health insurance, where we're trying to insure against some big medical event that we can't really cover because it's going to be too costly as opposed to kind of the more routine type of stuff that we would kind of cover, that we would pay for typically. That would be similar with the home. We would pay for the normal kind of upkeep type of stuff, but then try to cover against the house burning down. But with health insurance, obviously there's laws and regulations trying to get more of that routine stuff that will be covered. That's why we've got the co-pays and all these other kind of terms within the health insurance as they try to kind of expand health insurance and for various reasons that we've talked about. So now, of course, the question would be, well, okay, we've talked about what is covered, what's health insurance in general, what are the different terms of health insurance. Obviously now let's take a look at what isn't covered. Navigating health insurance coverage is a monumental task. Consumers generally have no say in which services are rendered, which services are covered, and how much they will ultimately be responsible for paying. So we've talked about in prior presentations your options in terms of purchasing insurance, and there are different options for purchasing insurance. However, once purchased, there will clearly be a lot of rules and regulations within that particular insurance package, which can be confusing and which we have to basically follow as we go through our medical procedures and the billing process related to it. It is not uncommon that a doctor requests a service. The patient follows the doctor's orders. Insurance pays only a portion or none at all, and the patient is left holding the bag and the bill. So in other words, as we're navigating our medical procedures, it's possible we're going to go to one doctor, they're going to point us to another doctor, and it can get quite confusing with all the different terms we've talked about, the copays and the deductibles and so on and so forth, in terms of what's the bill going to actually be, how much of that bill is going to be picked up by the insurance company, and how much of it is going to be picked up by us. The No Surprises Act, part of the Consolidated Appropriations Act of 2021, forbids patients from receiving surprise medical bills when seeking emergency services or certain services from out-of-network providers at in-network facilities. In other words, you would think that if you're within a certain network and you're in the network facility and that facility, you would think that you would be going to someone that would be an in-network provider, but that may not necessarily be the case, because you could have someone that doesn't have a contract with the same network that's in that same kind of area and you'd get a surprise bill, so they're going to try to safeguard against that kind of situation, because that seems a little bit deceptive if one doctor points you to another doctor, which is actually out of the network, but they're kind of in the same area. You're just going to assume it would be covered and possibly it wouldn't be in that case. So other common scenarios, a patient calls the doctor to ask for the price of a particular test or treatment, only to be told the price is unknown. So clearly, the billing process in terms of the medical industry is confusing in and of itself, because you've got the price, you've got the insurance companies that are going to be negotiated within the networks and then basically your cope. How much does it cost to you? So when you ask about the price, it can actually be a quite confusing question, because you might be asking, well, what's the price to me? How much is it total with the insurance company? How much would it be in-network and out-of-network? So you could see how these kind of confusions actually come up in the medical billing process, or a planned participant calls their health insurance to ask for the customary fee for a service to determine how much it will be covered only to be told it depends. So clearly, when you're trying to figure things out and you've got some service that maybe doesn't fall right into the standard routine, like a standard checkup, because we've talked about these terms in the past, that the government is trying to get more stuff that is the routine maintenance kind of stuff to be covered. And now you've got other terms that are called preventative care, that might have a different coverage than another kind of doctor visit, for example, where you might have a copay versus the deductible. So again, you could totally see why in the medical field when you call someone, you get an answer like that, it depends, because it's getting quite confusing with you're trying to categorize all these different procedures under these different categories which are covered in different ways, but as the consumer or on the consumer side, that can be quite frustrating. So no one would go into the local electronics store and buy a TV without being told the price, but in the medical care, this is basically what patients are expected to do. And I just don't think that's basically on purpose. A lot of times with the people that are working in the medical profession, I think part of this is the fact that there's a whole lot of confusion with all these different rules and regulations that leads to these ambiguous answers. So to be fair, and obviously these kind of rules and regulations aren't there when you buy a TV. No one's telling the TV shop there's no like rules and regulations to say, well, if they use this within their living room versus their bedroom, we get a discount, then you have to have a copay, and then if it's preventative care because it's blue light on the TV, then it might not be covered and the price is different, right? You don't have that kind of stuff because there's not as much kind of regulation involved when you buy a TV. So it's not really an apples to apple comparison, but I get the point. So to be fair, health insurance companies traditionally known as the gatekeepers to health care have recognized this and in recent years have tried to improve price transparency. Despite these efforts, there are many pitfalls associated with health insurance coverage. Learning how to navigate these should make for a more educated health care consumer. So here are the services that most insurers decline and a look at how you can get things covered that may initially be denied. So we've got the Medicare, the roadmap. So we've got the Medicare provides the most insight into covered benefits for consumers. So if you're looking Medicare, they're saying that there's a pretty decent roadmap for Medicare. So now obviously when we get into this kind of thing in terms of what's going to be covered and what's not going to be covered, it'll be dependent in part on the type of coverage that you have, the type of health insurance you have. We're talking here Medicare. The Medicare system is a federally run health insurance system granted primarily to U.S. citizens ages 65 and older. So in general, the basis for all health insurance benefits designed in the Medicare system. Many commercial health insurance plans model basic benefits after those benefits granted to Medicare recipients. So meaning if you get a general idea of the Medicare roadmap, a lot of times the private health insurance will also be mirroring that in part possibly because they're expecting regulations to force them possibly to do that at some point anyway. So it might be like just the easiest kind of thing to do. So you might be able to use that as a general roadmap in general. The focus is on health and wellness rather than sickness. Annual physical exams are not fully covered by Medicare and treatment for service for severe ailments also usually require a co-pay or co-insurance payment. However, preventative assessments. So here we get that key term again. And so when you're looking when you're talking just like in normal terms like Perlin's terms and you talk about, you know, your normal kind of doctor visits, you might call it like preventative care as your normal doctor visits. But when you start to get digging down into the insurance, then this becomes like a key term because they're trying to say that if something is preventative, we want to incentivize people to do the preventative stuff before they get the sickness or get sick in some way. And so they're going to try to give some incentives to do that possibly trying to lower the cost. So preventative assessments such as wellness visits and various screenings are included in Medicare Part B. So after the basic plan design is set for commercial health insurance, other benefits are added depending on the requirements of the plan's sponsor. For example, an employer. To understand the basics of what is covered under the Medicare plan, you can visit its website. So Medicare is not an early adopter system. Therefore, most new technologies are typically not covered at all or not covered as robustly as other more time-tested technologies. One example of this is drug alluding stents versus bare metal stents in cardiac procedures or ceramic hip replacement versus traditional metal ones. So it is much easier to obtain coverage for proven procedures rather than those that could potentially be deemed as test procedures. So clearly as technology advances, possibly having the hip made out of something other than metal and they're experimenting with other types of things which possibly could work out better. That's why they're basically going towards it might not be as covered because it's not as time-tested. So the fact that they're thinking it might be better doesn't necessarily mean it's meant that it will be better because we just don't have the numbers yet at this point in time. So similarly, covered lab tests are often lagging behind the newest technology. One example of this is the thin prep PAP test, which admittedly I don't know what that is. Services usually not covered. Although each benefit plan is different depending on the sponsor's needs and depending on state regulations, each state has its own insurance commissioner. There are services that are typically not covered by most health insurance plans. So we've got the cosmetic procedures. So you've probably heard about this, the cosmetic procedures. We've got another kind of categorization where the insurance might not kick in for certain categories. So many services that provide someone's exterior appearance such as plastic surgery and some dermatological procedures are usually not covered by typical insurance. Interestingly, because consumers elect to have these procedures, there is great price transparency for them. So it's kind of an interesting dynamic because the way the insurance is, we can see that there's a lot of regulation and so on within the insurance, trying to get the insurance to basically manipulate people's behavior to do more preventative stuff and so on. And the cosmetic surgery because it's not something that is required for your health care. It's more of a cosmetic type of thing, which is fine. But they're trying to say that that's not something that traditional insurance should be covering for. And you can see what the incentives would be if it were covered because if it were covered, it would probably subsidize that kind of surgery. And more people might have cosmetic surgery. Why not? Because it's covered or something like that. But in any case, the fact that it's not covered means that you have more market forces that are driving that on just a normal kind of free market kind of system that doesn't have as much influence by all the regulations and stuff that are kind of being put in place through the insurance. And it's not unsurprising then that you have more transparency in the price because they're competing on price and the quality of the service and so on. So it's kind of an interesting dynamic there. Remember who wants laser hair removal can call any number of providers and each one will be able to immediately quote a price. Ah, the free market. And note, it's probably true that there's less bloating in terms of the actual price too because they're competing in the price. Whereas when you ask something that's covered under the insurance, what the price is, one of the reasons they probably can't get to the price is because they're saying, What's the price we're going to charge? What's the price for in-network versus out-network? How much are we going to earn right? It gets kind of confusing. So we got the fertility treatments. The costs of many procedures often aren't covered by health insurance. Although health insurers are required to pay for all the tested required to make an infertility diagnosis. However, this is one of the treatment areas that differs among states. Currently, 19 states mandate coverage for fertility treatments. But even in those states, there are loopholes that allow employers of certain sizes to decline coverage. If covered by a fully insured plan, the company must follow the state insurance laws. Self-insured plans are exempt from the state's stipulations and can decline coverage. Off-label prescriptions. Prescription drugs are tested and approved for specific disorders such as autoimmune diseases. At times, these drugs can be prescribed for disorders not listed on the label. In some cases, the insurance company may reject paying for these off-label uses. So if they're not, you know, obviously if the thing is designed for a specific purpose, that's kind of what has been tested for is that particular purpose. And if you, you know, if you deviate from that, you can see why they might be skeptical to be assigning it for something else. Occasionally, physicians can argue for the coverage of off-label prescriptions for specific uses by offering peer-reviewed research supporting prescription. But insurance companies are not obligated to cover them. New technology and products or services. Covering these costs often happens slowly, particularly in the technology does not demonstrate an added benefit for the increased cost. So when you got the new technology and the medical profession, they're typically going to go and you can see why this would be the case. They're going to default to the time-tested things. And because, and I think I believe in the Hippocratic oath, there's something that says basically the first one of the rules is you do no harm. You're not going to try to make things worse. And oftentimes when we're drowning, for example, we wave our arms around like crazy, which is probably going to make us drown faster. So you don't want to get overwhelmed in all the new technologies for a lot of different things, unless of course you're basically at the point of death, like in your at a terminal kind of stage where you might be saying, hey, I'm willing to up the risk factor at this point in time. Given the fact that my, you know, my expectancy is so low, I mean, I don't have any much to lose at that point. So there's kind of a play between it. And at that point in time, that point in people's lives, when it might be more sense to take more risks, is where the current health insurance might fall short more often as it kind of defaults to this idea that it's not going to, it's not going to adapt new technology very quickly. And part of that is also due to not just the medical profession trying to be more, trying not to take actions that they don't need to take actions, but also because they don't want to get sued and things like that, which isn't. In any case, medical companies are tasked with providing that a new drug product or test provides measurable benefit to the consumers such that the cost will improve mortality or mobility rates basically save lives or reduce ill health, because Medicare is not an early adopter of new technology. Other insurance plans generally follow suit and wait for more data before including it in the covered benefits. So what's your resource? Although there are services not typically covered, there are special cases in which insurance companies do make exceptions and cover these services. However, for many instances in which services are not covered, there are several other courses of actions that consumers can take. Get covered for new technology. So if you got some new technology and you're trying to use the new technology, what can you do to get covered for that kind of stuff? And again, if you're getting into new technology and you're healthy, then I kind of lean towards the more conservative idea generally that you want to be leaning towards the more time-tested stuff because just because it's new doesn't mean it's good. It's not time-tested. That's the point. But if you had a point where you're really sick and there's new stuff out there that might be helping you, then again, the math changes at that point in time because you don't have as much to lose in my opinion. But in any case, for cases in which a new technology provides additional benefits, as opposed to the older technology, consumers can try several methods for getting the insurance company to pay. Many insurance companies require a doctor to quote, prove, end quote, why the costlier procedure or product is more beneficial. Additionally, an insurance company may pay a specific amount for a procedure and the patient can pay the difference to get the new technology. In other words, partial coverage is available. The first step in this process is to discuss the coverage with the insurance company, determine what will be covered and have an agreement with the physician for the total cost and what you will be required to pay. So you've got to kind of nail things down a lot more specifically. You would think in those instances because you're in a gray area and you would be asking specifically the insurance company, what is it exactly that you would cover because you're probably not going to find this new technology procedure with the cost of things with the co-pays on it or anything like that. So you want to nail that down and you also want to nail it down with the doctors to see how much they're actually going to charge. Because again, it's not something that's got to set price to it possibly because it's a new procedure and then you might be able to move forward with your decision from there. Medical device companies can also lobby for inclusion within the Medicare system. They have applied for a new technology add-on payment. So if accepted, Medicare will cover a portion of the device cost or the incremental costs associated with it. Get covered for new drugs. Many new drugs or services introduced in the market undergo trials to test additional benefits or uses. Consumers can try to get into one of the trials and get the service or products as part of the trial. So you can get into the new drug trial again. To me, I'm kind of dubious on getting into the new drugs because I do kind of feel like why take the drug that's not tested because you're taking on more risk for something that hasn't been tested as much or hasn't been as time tested unless you're at a point where you think the benefits are worth the risk. So however, although each trial is designed differently, many have a group of participants who receive a placebo, a fake treatment, so you are not guaranteed the drug or service. Your physician should be able to inform you of any trials available as the Food and Drug Administration. The FDA requires listing of drug trials. Purchase an insurance plan rider. Health insurance companies provide insurance-insured persons with the option to purchase a rider and an added policy feature for a specific covered benefit. However, these riders can be costly and may not be available for purchase for all treatments. Appeal a denial. So you get denied appeal. I am going to take you to the appeal process. Covered persons can contest a denial by an insurance company. Each insurance company is required to provide an insurance person with the procedure required to appeal. So if they say, I'm not covering that, you might say, well, I want to contest your opinion there based on the rules and regulations of the coverage procedures and get another opinion. So in addition, if the appeals process result in another denial, the insured consumer can appeal to the state insurance commissioner for a review of the case. So you can take it up kind of like a legal battle there, but it's going to be in accordance with whatever the laws and regulations are in the medical industry and the contract that you have set up with the insurance company. The process can be somewhat lengthy, but often without cost to the insured person. Other insurance pitfalls. Some doctors, some doctors offices will help cut consumers, navigate the insurance maze to determine coverage. However, as the consumer, it's always wise to speak directly with the insurance company to validate that a procedure is covered. So in other words, sometimes because the doctors are kind of like in this web in the network, they might understand things better and you might sign some doctors that are good advocates, not only of your health, but to your insurance company to see what's going to be covered, which is nice, but you probably don't want to be depending on that because you're probably going to find other doctors that aren't as up to date on that kind of thing, right? They're into their doctoring, not really into the whole insurance thing. They might not even like that they're kind of in the network, you know, at the same time that the way the whole healthcare system has kind of evolved these days. So you want to be doing your own kind of research on that side of things so that you can have an understanding of what is going on and you can make your own decisions with that information. Frustratingly, insurance companies will sometimes decline to speak with an insured member and speak only with the physician's office, but persistence generally pays off. So you're going to be like, well, I'm the person paying that's insured here, you know, I want the information. So there are many other pitfalls of insurance coverage that consumers should be aware. Some of the most common are pre-approval. Many insurance plans require pre-approval or prior authorization for certain healthcare services such as surgeries or hospital stays. You or your doctor must contact the insurer before you receive care to get authorization. If you don't, the service may not be covered by your insurance in-network versus out-of-network. So many insurance plans such as health maintenance organizations, the HMOs are designed with in-network doctors and facilities. These in-network providers often have a contract negotiated with the insurance company to pay an agreed-upon price for various services. It's also important to ensure that all the components of a procedure are covered. Check, for example, that not only a surgeon and the hospital are in-network, but also the anesthesiologist and make sure tests are sent to an in-network or preferred lab. Prescription drug costs. The cost and coverage of prescription drugs vary depending on a plan's formulary. The formulary, typically found on a health insurer's website, details cheaper drugs via their tier status. Prices go up from tier 1 to tier 3, and sometimes tier 4 substitutes or generic versions of the drugs. Also, some specialty drugs such as injected drugs may require additional pre-approval before an insurance company will pay for them. Some insurance plans only count a portion of the cost of higher-tier drugs toward your total deductible in a practice called copay accumulator adjustment programs. How are excluded services and devices determined by health insurers? Most health insurance companies use Medicare as a roadmap for what will and will not be covered. That's kind of why we started out here with the Medicare, because a lot of times that can be used as the roadmap for insurance companies to give you good general ground line basis. Medicare tends to be conservative in its adoption of new drugs, therapies, and devices, so cutting-edge technology will often be deemed too expensive or experimental for coverage. So you got that same kind of idea with the medical care where they're going to say, if something is really new, they're going to tend towards not going towards the new thing because it's not as time-tested. So what kinds of services are typically not covered by health insurance? Though coverage can vary case-by-case, some procedures are seldom covered. Cosmetic procedures such as plastic surgery or vein removal are nearly always considered elective and so are not covered. Fertility treatment are only covered in certain states, and even then there are loopholes that allow insurers to deny coverage. New medical devices are often not covered until there have been years of evidence of their value versus costs. Some prescription medications that are prescribed for off-label use may also be denied. There are avenues to appeal a denial. Yes, you may appeal and insurers denial of your claim. Typically your insurer will expect you to work with your physician's office to provide justification for the need for the treatment, drug, or device, and it still may not be approved. So in other words, if there's an appeal, they deny something, you would typically go to your physician, your doctor, who would then be providing you and telling you why it would be an appropriate thing to be doing. You're going to gather the evidence and the appeals process and probably try to argue your case from that point. You may appeal beyond your health insurance company with the state insurance commissioner. Is there a way to anticipate how much a treatment or service will cost? Although the transparency and coverage proposed rule intended to make prices available to all hospital systems and providers have been slow to adopt it, the only true way to know what price you'll pay is by speaking to a representative of your insurance company. Some companies require pre-authorization or approval for services to be covered as well. Check the language of your plan and get your approval in writing. What's the bottom line? Understand in working with the guidelines of health insurance is complex. Many companies provide members with access to a vast amount of information on secure websites. This information can help members select a doctor or facility review the drug formulary and learn other key information, but to understand what is covered benefit having a live discussion with an insurance representative is the best course of action. As higher percentages of health care costs are pushed to insurance plan members, more of the quote shopping end quote decisions should also be made by members.