Your Health Insurance - and what it should Cover

Part 2: …and what it should Cover

Part 1 of this series analyzed the costs that you pay under your healthcare insurance plan. In this article we’ll look at some of the basic coverages which should be included in your policy. Don’t ever assume that everything is covered, because it isn’t. Inexpensive policies (read, cheap) cover very little. Whether you have a tradition plan or an HMO, employer-provided or an individual policy, you’re much better off with a comprehensive, major medical health insurance plan that should cover the following:

  • The cost of basic hospital services - This includes a semiprivate room, food, emergency room, nursing, intensive care, ambulance service, medicines, X-rays and lab tests. Unless your plan deems it medically necessary, the extra cost of a private room will be yours.
  • The cost of surgery - This should include surgeons, assistant surgeons, anesthesiologists, and outpatient surgery. The plan will cover the costs that are “usual and customary” for your area.
  • The cost of outpatient care - Many procedures that previously required hospitalization are now done on an outpatient basis. To prevent infections and other unforeseen effects, your policy should provide adequate home healthcare support.
  • At least part of the bill for home health care - This should be covered if ordered by your doctor.
  • Most doctor bills - In full or in part; again, the plan will only pay up to the “usual and customary” charges.
  • Good coverage for your children - Stepchildren and foster children should also be included if you’re responsible for their support. Be aware of how long your children can remain on your policy. Typically, they’re covered up to age 19 if not full-time students, and anywhere from 21 to 25 if they are. Children with mental or physical handicaps who cannot support themselves should be covered permanently, as long as the disability occurred while they were insured.
  • Care for an infant from the moment of birth - Generally, to have your child included on your health plan, you must notify the insurer of the birth within thirty days. The majority of group and individual plans provide infants with major medical coverage from the moment of birth; however, they may not cover therapy for all birth defects.
  • Part of the cost of convalescing in a nursing home - After you’ve had a hospital stay, but you still require nursing care.
  • Part of the cost of prescription drugs.
  • Part of the treatment for mental problems, drug- and alcohol abuse - This area of coverage has seen many recent cutbacks and is subject to strict oversight.
  • Most of the cost of incidental expenses - These can include physical therapy, oxygen, durable medical equipment (DME), and the like.
  • Part of the cost of oral surgery - Dental surgery generally isn’t covered under standard health insurance plans, but can usually be included with a rider.

Finally, don’t be satisfied by receiving just a sales brochure that states in advertising lingo that everything is covered. Everything isn’t. Get a copy of the contract which shows exactly what’s insured as well as how much of the expenses you’re expected to pay.