The Limitations of Health Insurance Plans


Every day, the costs of living rise, and healthcare costs make insurance cover an attractive solution. Health insurance plans offer mental peace for subscribers. An individual’s choice of a plan depends on their ability to afford it. However, sometimes people go beyond their means to obtain the benefits of a particular cover.

The incidence and prevalence of lifestyle diseases have made the need for insurance move from an option to a must-have. Generally, insurance providers promise to make the cost of catering for health easier that is not always the case. Sometimes there are limits to what a plan covers.

Advantages of insurance covers

Having a health cover is essential because;

  •         Illnesses burden the person in need of care and their families as they have to gather funds to oversee the costs. With insurance coverage, part of the expenses is covered, thus preventing people from unnecessary debts.
  •         It is easier to have the health plan cover medical expenses compared to liquidating assets in case of urgent care.
  •         With a cover, a person can relax knowing that they do not have to use their life savings to cover medical costs.

Services covered by insurance plans

When one wants to purchase a health plan, they have to examine each plan’s services and exclusions. Before the Affordable Care Act, there were variations in the coverage plan. One of the significant reforms in the US health sector through the act involves insurance plans.  According to the act, insurance plans must cover some essential services. These services include;

  •         Emergency services
  •         Hospitalization
  •         Laboratory tests
  •         Maternal and newborn care
  •         Mental health and substance abuse treatment
  •         Outpatient care
  •         Pediatric services including vision and dental care
  •         Prescription drugs
  •         Preventive services including some immunizations
  •         Management of chronic conditions
  •         Rehabilitation services

The plan may include these services, but there will be cost variations in the premiums due to the other services that a person needs their insurer to cover.

Exclusions in Health Plans | Health Insurance Plans

When signing up for an insurance plan, the providers ask questions to assess your eligibility for specific covers. The providers set boundaries on what they cover by excluding some services. Some of these exclusions include;

  •         Cosmetic surgery – Insurers avoid paying for this type of surgery. They set up conditions when they can pay for the services, such as if the doctor determines it a necessary part of medical care. Providers insist that when they cover the surgery, it must be when reconstruction is done due to an injury or to correct a congenital disability. The drugs used for cosmetic-only value have not covered the plans. However, some high-end plans may include it, but you would have to be every reach to qualify.
  •         Pre-existing conditions – Insurers often offer a waiting period to watch out for a relapse before providing coverage. The typical waiting period lasts from six months to twelve months.
  •         Alternative treatments – More often than not, health insurers do not cover treatments that go against or substitute conventional medicine. Some alternative or complementary medicine that people engage in are yoga, acupressure, acupuncture, and massage. Some plans consider chiropractic care as alternative medicine. Thus they do not cover it. Insurers do not cover food supplements or any drugs they consider experimental.
  •         Private nursing and home care – Health insurers do not cover the expenses that arise from utilizing the services. According to the CDC, at least 1.4 million people use the services. On average, a patient may require a minimum of sixty days of care.
  •         Mental health treatment – Coverage depends on the health plan a person is using. Some cover and treatment and rehabilitation drugs, while others do not or have many conditions. Instead, employers have employee assistance programs to offer mental health and substance abuse services.
  •         Abortion services – Insurers do not cover elective procedures and the drugs used in terminating a pregnancy.

The insurance coverage a person is using has its exclusions and limitations. Due to the many variations in plans, it may be hard to pinpoint the specific limitations and exclusions in every insurance cover. To ensure you understand the benefits, limitations, and exclusions, you need to read the Summary Plan Description (SDP). The SDP, which a person can get from the insurer or your human resource department provides details about the policy rules, limits, and bylaws.

Every financial year, there are factors such as the inflation levels that affect the covers’ pricing. In the year 2020, the pandemic has brought more elements to the health insurance market, including adopting telehealth services to deliver care.

As health plans make adjustments to cater to the treatment plans, the cost of care will only rise. Insurers have already found new market opportunities. Some fully cover telehealth utilization while others limit. With Covid-19, the lines are still blurry. Some programs may cover drugs and intensive care, while others may not. The option is to wait and see.