Understanding Health Insurance

By: Lee Ann Obringer & Melissa Jeffries

Typical Insurance Limitations and Exclusions

Face lifts aren't covered by insurance.
Face lifts aren't covered by insurance.
©2007 Santa Barbara Plastic Surgery Center

Polices will vary quite a bit on their limitations and exclusions so it's always very important to read the actual policy (not the marketing information) carefully before making a selection. Here are some limitations and exclusions common for many health insurance policies:

  • Pre-existing conditionsMost health plans will have waiting periods of six months to a year for pre-existing conditions if you have had a lapse in health insurance coverage that's longer than 63 days. For example, if you're diabetic and leave your job but don't begin a new job right away, you would have to pick up an individual insurance policy or find coverage somewhere else (through a spouse's employment, for instance) in order to avoid a waiting period with your next policy.
  • Cosmetic surgeryHealth insurance rarely covers cosmetic surgeries. Usually they must be for reconstructive purposes after an injury or due to a birth defect. They may also be covered if a doctor states that there's a medical need for it such as a reconstruction of a clef palate. That means that the face lift or liposuction that you have your heart set on must be paid out of your own pocket.
  • Non-traditional treatments Alternative and complementary medicine often isn't covered by health insurance. Alternative medicine is defined as treatments that are used in place of conventional medicine and complementary medicine refers to treatments and procedures that are used together with conventional medicine. These types of treatments include acupuncture, yoga, acupressure, massage and biofeedback. In some health insurance plans, even chiropractic treatments can fall under alternative medicine and therefore isn't covered. These services often aren't covered as they're considered by health care companies as experimental or non-traditional in nature.
  • Home care and private nursing care Home care and private nursing expenses are some of the most common expenses that aren't covered under your insurance plan. According to the CDC there are over 1.4 million patients using home health care with the average patient needing at least 60 days of treatment. Without any coverage, these health care expenses can add up fast and end up bankrupting patients and their families.
  • Mental health treatment Some plans cover mental health treatment as well as drug rehabilitation. Although, some only cover substance abuse if it co-occurs with mental illness. To get access to these types of services you may be required to get a referral from your regular doctor first. Mental health and substance abuse services may also be offered through an employee assistance program (EAP) if your employer has one.
  • Common Drug Benefit ExclusionsIn addition to the procedures, treatments, and surgeries discussed above, many exclusions fall under drug benefit exclusions. Many of the drug benefits that are excluded can be included in the same cosmetic or nontraditional categories as those mentioned above. Drugs used only for cosmetic purposes usually aren't covered by your plan. These can include hair growth stimulants and supplements for clear skin or strong nails. Non traditional drugs like food supplements and any drug considered experimental are usually not included in your plan either. Like elective abortions, drugs that are used to abort a pregnancy also aren't covered for the same political reasons.

Along with limitations and exclusions in your health insurance policy, waiting periods can also affect your overall health care. Find out more about how these waiting periods work and how some can be eliminated all together.