Options If Insurance Does Not Cover a Service You Need

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 healthcare provider. "People make the assumption that if the doctor orders it, it's going to be covered," says J.P. Wieske of the Council for Affordable Health Coverage, an insurance industry lobbying group. But that's not always the case.

This article will explain the basic coverage rules that health plans must follow, as well as next steps if you find out that a service you need is not covered by your health plan.

Healthcare providers view your condition from a medical perspective, 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 an exclusion or waiting period 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 (i.e., 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 and self-insured plans don't have to cover essential health benefits, and neither do grandfathered/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.

However, 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.

And it's important to understand that even if a service is "covered," you might have to pay the full cost yourself (after the network negotiated discount). This would be the case, for example, if a deductible applies and you haven't yet met the deductible earlier in the year.

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 healthcare provider'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 healthcare provider'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. Try speaking with someone in person, rather than on the phone, and don't take no for an answer on the first round.
• Appeal to the insurance provider:  Ask your healthcare provider for the medical codes of the recommended procedures, and investigate your insurance company's appeal process. If your health plan is non-grandfathered (i.e., 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.
• Reach out to your state's insurance commissioner. If your health plan is not self-insured, the insurance commissioner in your state is in charge of regulating it (self-insured plans, which cover the majority of people with large group coverage, are regulated by the federal government instead, under ERISA). They can let you know whether your health plan might be running afoul of any specific rules. The National Association of Insurance Commissioners can provide the contact information for your state's insurance department.
• Investigate clinical trials: If you're a candidate for a clinical trial, its sponsors may cover the cost of many tests, procedures, prescriptions, and healthcare provider 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 (i.e., non-experimental care) while you're participating in the clinical trial. These requirements are part of the Affordable Care Act. Before 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 healthcare provider may suggest alternate treatments, or he or she may confirm the advice of your primary healthcare provider. Many insurance providers pay for second opinions but check with yours to see if any special procedures should be followed. Your healthcare provider, 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 healthcare provider's office to work with you to pay the bill over time.

Summary

Most health insurance plans cover most medical services that members need. But sometimes a doctor recommends a service that isn't covered, which can be challenging for the patient. Fortunately, there is an appeals process that patients and their doctors can use, and there may also be alternative medical procedures that would suffice and that are covered by the health plan.

A Word From Verywell

The better you understand your health plan, and the better you follow its rules, the less likely you are to be surprised by rejected claims. It's a good idea to discuss upcoming procedures with your health plan in advance, even if prior authorization isn't specifically required.

And if your doctor recommends a procedure that isn't covered by your plan, don't be shy about discussing your health coverage with your doctor and asking if a different procedure—that is covered by your plan—would suffice. But also be aware of your appeal rights, and know that you don't have to simply accept your insurer's initial "no" as the only answer.