MetroPlus Home
LEARN
Benefit Basics
divider Health Coverage Plan Costs In and Out of Network Dental Coverage Know Before You Go Types of Care Bills and Documentation Your Rights

Healthcare Services Not Covered by Health Insurance

print

 

flexspendingYou might think your health insurance plan will cover just about anything, from eyeglasses to private nursing. But you would probably be wrong. There are some healthcare services that most health plans don’t cover.

 

This guide will tell you about:

  • Healthcare services that aren’t typically covered by health plans; and
  • What you can do if you want one of those services.

What Healthcare Services Often Aren’t Covered?

Under current law, nearly all health plans have to cover certain essential benefits. Those include, among others, emergency services, hospital stays and prescription drugs. To see a complete list, check the HealthCare.gov site here.

Below is a list of services usually not covered.

  1. Adult Dental Services

All adults need dental care, but it’s generally not covered by medical insurance. Look into getting a dental insurance plan. If you’re retired, see our article on dental coverage for retirees. If you’re eligible for Medicare, note that some Medicare Advantage plans cover dental, vision and hearing.

  1. Vision Services

Nearly all plans cover medically necessary visits to an eye doctor. But, they usually don’t cover eyeglasses, contact lenses or discounted eye exams. Explore a vision insurance plan.

  1. Hearing Aids

Some states require health plans to cover hearing aids, but most don’t. The Hearing Loss Association of America provides information about assistance programs for hearing aids, including programs in each state. AARP offers a hearing care program for members. Audiology students can perform hearing treatments less expensively than many practicing audiologists. You may be able to buy hearing aids at lower prices from a warehouse club.

  1. Uncovered Prescription Drugs

Health insurers do not have to pay for all medications. They list their covered medications in what’s called a formulary. If your drug isn’t on that list, it probably won’t be covered. Suppose a drug is meant for one use, and your doctor prescribed it for another use. That’s known as off-label use. Your insurer may refuse to pay for the off-label use.

Ask your doctor if you can take a covered drug that would be just as safe and effective as the one that’s uncovered. If not, ask your doctor to request the insurer to make an exception based on medical necessity. If that request is denied, you can file an appeal with your insurer. That means asking for your case to be formally reconsidered.

  1. Acupuncture and Other Alternative Therapies

Millions of Americans are turning to acupuncture, in which needles are inserted in the body as treatment. But, like other alternative therapies, acupuncture may not be covered by health plans. Such therapies are usually looked at as nontraditional or experimental.

If your insurer says your therapy is experimental, you can appeal and try to get it covered. You and your provider may be able to show proof that the therapy works. See Experimental Treatments and Clinical Trials. You also can seek out health-related discounts on certain services from online coupon sites. Those services may include acupuncture, weight loss programs and cosmetic surgery.

  1. Weight Loss Programs and Weight Loss Surgery

Obesity is bad for your health. While some health plans cover nutritional counseling, weight loss programs and weight loss surgery (known as bariatric surgery), others don’t. Check with your insurer to see if it covers these treatments. Some plans offer incentives for various wellness programs that address obesity, such as gym memberships. 

  1. Cosmetic Surgery

Cosmetic surgery is surgery to improve appearance. In some cases, most health plans are required to pay for cosmetic surgery, such as breast reconstruction surgery after a mastectomy. Other times, insurers will cover plastic surgery if they believe it’s medically necessary. An example would be a nose job for a patient with a problem breathing. But, most cases of cosmetic surgery are unlikely to be covered.

  1. Infertility Treatment

Infertility is the inability to have children. In some states, insurers are required either to cover or offer coverage for diagnosis and treatment of infertility. But, in many states, infertility doesn’t have to be covered.

  1. Sterilization Reversal

Many plans cover sterilization surgery to make you unable to have children. But, most don’t cover reversals of such surgery.

  1. Private Nursing

Many senior citizens depend on private nurses. But, most insurers don’t cover private nursing.

  1. Travel Vaccines

If you’re visiting an exotic foreign location, insurers may not cover travel vaccines. Those are vaccines for diseases that are not a problem where you live. They are seen as elective (something you choose) and nonessential.

  1. LASIK

LASIK, or laser surgery to fix the cornea, a part of the eye, is popular. But, since it’s elective and viewed as nonessential, it’s often not covered by insurance.

What to Do If You Want an Uncovered Service

A flexible spending plan can help you pay for any healthcare expense, whether it’s covered or not. It just has to be a “qualified medical expense.” That’s an item that the Internal Revenue Service (IRS) says you can deduct as a medical or dental expense on your taxes. Flexible spending plans help you save money by letting you spend pretax dollars. That’s money that you earn but that hasn’t been taxed.

If you can’t afford an uncovered procedure, medical assistance program may be able to help. You also may be able to negotiate your bill with the provider. To do that, find out what the procedure usually costs in your area by using FAIR Health’s lookup tools for medical and dental expenses. Is the usual price lower than the provider’s price? Then, you can use that information to talk about cost with the provider. You also can use the lookup tools to plan and budget for the cost.

Your Action Plan: When Your Insurer Won’t Cover Certain Healthcare Services

  • Look into the solutions suggested for dental, vision, hearing, prescription drugs and alternative therapies.
  • Set up a flexible spending plan to help pay for uncovered medical expenses.
  • Consider using a medical assistance program to help you pay your medical bills.
  • Try to negotiate your bill with the provider.

Use FAIR Health’s lookup tools to budget for the cost.