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Health Insurance: What Procedures or Medication will Insurers not pay for?

Health insurance is a wonderful way to have your health needs met, from prevention to treatment, while having to pay for the medical care each time. Instead, you pay a premium that is deducted from your checking account or is given to the insurance company in the form of a check. Some companies you might work for will have health insurance as a benefit or may reduce your paycheck by the amount of the premium at each paycheck.

Insurance companies will pay for most preventative medicine, including mammograms, general physicals (sometimes just one per year), colon cancer screening (at a specific rate) and other preventative testing and screening tests. They will also pay for most illness-related doctor’s visits and treatment for those illnesses. X-rays are generally paid for as are most blood tests. For the average person, health insurance can be a big bonus and can allow you to be sick or to prevent sickness without fear of what you’d have to pay for.

The things an insurance company does not cover for is provided in a Notice of Noncoverage. There they list the things that are definitely not covered under the insurance plan. There are sometimes different levels of coverage so that if you pay more, you will have more things covered under your insurance plan.

Things that are not generally covered under the insurance plans are dialysis, which is the procedure that removes toxins from the blood in those individuals who suffer from kidney failure. Dialysis is very expensive, involving having all day treatments several times per week. Transplants, too, are generally not covered under many insurance plans unless yours is one that has agreed to transplants in advance. This includes kidney transplants, heart transplants, liver transplants and heart/lung transplants. Sometimes a transplant is approved after going through an approval committee but is not guaranteed.

Certain chemotherapy treatments for cancer are not covered, especially if the chemotherapy agent is new. New chemotherapy agents are sometimes considered “experimental” and experimental treatments are generally not covered under most insurance plans. In rare cases, if the medical data is available showing the effectiveness of a drug is proven to the insurance company, the company may pay for the drug. This is true of all experimental drugs and therapies.

Mental health coverage varies from insurance company to insurance company. Some companies will pay for no outpatient mental health services but will pay for a certain number of days of inpatient mental health services. Other insurance companies cap the number of outpatient mental health therapies at an arbitrary 20 or 30 sessions per year. After that, you have to pay for your own mental health therapy. Sometimes a doctor or therapist can appeal to the insurance company for further sessions allowable by the insurance company and the payer will pay for more sessions.

Each insurance company is different and you have to read the brochure to find out what is and what is not covered straight off before choosing the insurance company. What is covered by some insurance companies completely is not covered at all by other insurance companies.


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