Options If Insurance Does Not Cover a Routine Procedure

How can you make sure the treatment you need is covered by your health insurance? Know your insurance policy, understand your options and talk with your doctor. "People make the assumption if the doctor orders it, it's going to be covered," says J.P. Wieske of the Council for Affordable Insurance, an insurance industry lobbying group.

A patient consulting with a doctor
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Doctors view your condition through a medical perspective, though, not from an insurance standpoint. Since they see patients who have a variety of insurance providers, they're often not as aware of the coverage provided by a particular company or plan as patients are – or should be.

Insurance policies are geared toward a broad population, so covered items are based on standard medical procedures for the average patient. Patients, though, have more alternatives – and more successes – in negotiating health care costs and benefits than many realize.

The Affordable Care Act's Effect on Coverage

The Affordable Care Act, enacted in 2010 (but mostly implemented in 2014) made sweeping changes to the regulations that pertain to health insurance coverage, especially in the individual and small group markets.

Under the new rules, health plans cannot exclude pre-existing conditions or apply pre-existing condition waiting periods (note that this rule does not apply to grandmothered or grandfathered individual market plans – the kind you buy on your own, as opposed to obtaining from an employer – but nobody has been able to enroll in a grandfathered individual market plan since March 2010, or in a grandmothered individual market plan since the end of 2013).

So if you're enrolling in your employer's plan or purchasing a new plan in the individual market, you no longer need to worry that you'll have a waiting period or exclusion for your pre-existing condition.

In addition, all non-grandfathered plans must cover a comprehensive (but specific) list of preventive care with no cost-sharing (ie, you don't have to pay anything other than your premiums), and all non-grandfathered, non-grandmothered individual and small group plans must also cover the ACA's essential health benefits with no dollar limit on the coverage. 

All plans—including grandfathered plans—are banned from applying lifetime benefit maximums on essential health benefits. Large group plans don't have to cover essential health benefits, and neither do grandfathered or grandmothered individual and small group plans. But to the extent that they do cover essential health benefits, they can't cut off your coverage at a particular point as a result of a lifetime benefit limit (grandfathered plans can still have annual benefit caps on essential health benefits).

All of these provisions have helped to ensure that people get fewer claim denials than they did in the past. But no policy covers everything. Insurers still reject prior authorization requests and claims still get denied. Ultimately, the onus is on each of us to ensure that we understand what our policy covers, what it doesn't cover, and how to appeal when an insurer doesn't cover something.

What to Do When a Procedure or Test Is Not Covered

  • Ask About Alternatives: Will a similar test or treatment that is covered by your insurance be just as effective as one that is not?
  • Talk with Your Doctor's Office: If you're going to have to pay out of pocket because the procedure isn't covered by your insurer, talk with your doctor's office to see if you can get a discount. You're usually better off talking with an office manager or social worker than the medical provider. Success is even more likely if you speak with someone in person, rather than on the phone, and don't take no for an answer on the first round, according to the National Endowment for Financial Education.
  • Appeal to the insurance provider:  Ask your doctor for the medical codes of the recommended procedures, and investigate your insurance company's appeal process. If your health plan is non-grandfathered (ie, it took effect after March 23, 2010), the Affordable Care Act requires it to adhere to the new rules for an internal and external review process.
  • Investigate Clinical Trials: If you're a candidate for a clinical trial, its sponsors may cover the cost of many tests, procedures, prescriptions and doctor visits. Your insurance company can deny coverage of the clinical trial itself, but cannot discriminate against you for participating in the clinical trial, and must continue to cover in-network routine care (ie, non-experimental care) while you're participating in the clinical trial. These requirements are part of the Affordable Care Act. Prior to 2014, when the ACA changed the rules, insurers in many states could deny all coverage while a patient was participating in a clinical trial. That is no longer allowed, thanks to the ACA.
  • Get a Second Opinion: Another physician may suggest alternate treatments, or he or she may confirm the advice of your primary doctor. Many insurance providers pay for second opinions but check with yours to see if any special procedures should be followed. Your doctor, trustworthy friends or relatives, university teaching hospitals and medical societies can provide you with names of medical professionals.
  • Suggest a Payment Plan: If the treatment is essential and not covered by insurance, ask your doctor's office to work with you to pay the bill over a period of time.
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Article Sources
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  1. Centers for Medicare and Medicaid Services. Center for Consumer Information and Insurance Oversight. Affordable Care Act Implementation FAQs—Set 15.

  2. Norris L. Should I keep my grandmothered health plan?. healthinsurance.org. January 31, 2020.

  3. Centers for Medicare and Medicaid Services. Frequently asked questions on essential health benefits bulletin. December 16, 2011.

  4. HealthCare.gov. Health Insurance Rights & Protections. Grandfathered Health Plans.

  5. The University of Illinois College of Medicine. Health insurance coverage of clinical trials.

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