Trying to navigate the U.S. health insurance system feels like untangling a ball of Christmas lights while blindfolded. It is messy, frustrating, and easy to get lost. If you are part of the 87.8 percent of Americans who had health insurance in 2017, you likely think you have a handle on it. You know what is covered. You know what you will pay.
Think again.
One bad accident or an unexpected emergency procedure can wipe out your savings if you misunderstand the fine print. The system is riddled with loopholes. Even if you believe you are an expert on your policy, these six common gaps in coverage might shock you.
Which States Require Private Insurance to Cover Hearing Aids?
Hearing loss is the most common disabling condition in the United States. About 48 million Americans suffer from it. By age 65, one out of every three people is affected. Despite this prevalence, coverage is sparse.
Medicare, the federal safety net for older Americans, typically does not cover hearing aids. Most private employer plans and individual policies follow suit. They might pay for a hearing exam. They rarely pay for the device itself. Insurance companies classify hearing aids as “elective.”
There are very few exceptions. Only four states mandate that private insurance plans cover hearing aids for both adults and children:
- Arkansas
- Connecticut
- New Hampshire
- Rhode Island
Another 18 states require coverage for children’s hearing aids. Wisconsin is the only state that explicitly requires coverage for cochlear implants. If you live outside these jurisdictions, you are likely paying out of pocket for what should be a basic medical necessity.
Why Does Medicare Not Pay for Long-Term Nursing Home Care?
This is one of the biggest ironies in American healthcare. Neither Medicare nor standard private insurance will help pay for long-term nursing home care.
Medicare might cover short stays in skilled nursing facilities for rehabilitation. If you break a hip and need physical therapy, they will pay. But they will not pay for “custodial care.” This is the daily assistance most people associate with nursing homes—dressing, bathing, feeding.
To cover this, you need separate long-term care insurance. These policies are expensive and often difficult to qualify for as you age.
So how do people afford nursing homes? Karen Pollitz, a senior fellow at the Kaiser Family Foundation, explains that Medicaid is the only program that pays a portion of these costs. But there is a catch. You must spend down your assets to poverty levels first.
“You have to spend yourself into poverty Medicaid levels and then the bills will get paid at that point,” Pollitz says. It is a brutal financial test before the state steps in.
Are Experimental Therapies Covered by Insurance?
The U.S. leads the world in medical innovation. Researchers are constantly developing new therapies for cancer, dementia, and more. But access to these treatments is not guaranteed.
Unless you are selected for a clinical trial—and even then, you might end up in the placebo group—you will likely pay for non-FDA approved therapies yourself. Insurance companies are hesitant to cover experimental drugs. They want proven results.
There are rare exceptions. You and your doctor can petition your insurer to cover an experimental therapy if it is cheaper than the conventional treatment. If the insurer sees that the new drug will save them money in the long run, they might agree. But this is a difficult battle to win.
Do In-Network Hospitals Guarantee In-Network Doctors?
This is where surprise medical bills are born. It is one of the most common sources of unpaid bills, according to Pollitz.
Here is the trap: The hospital is in your network. The facility is covered. But the doctor who performs your surgery is not.
Many insurance policies cap your out-of-pocket costs for in-network providers. But some policies cover zero percent of out-of-network costs. If you have surgery at an in-network hospital, the anesthesiologist or pathologist may be out-of-network. They work at the hospital but are not employed by it.
Your insurance may deny the claim for their services. You get the full bill.
“Unless you’re awake enough to ask doctor before they step in the room, ‘Wait a minute! What plans to you participate in?’ There’s a good chance that you could end up with at least one surprise medical bill,” Pollitz warns. It is nearly impossible to verify every provider in the room before you go under anesthesia.
Does Health Insurance Cover IVF and Infertility Treatments?
Infertility affects many couples. Yet, coverage is limited. Only 15 states have laws requiring infertility treatment in insurance plans. Some of those states explicitly exclude in vitro fertilization (IVF).
IVF is expensive. A single round costs between $12,000 and $15,000. The success rate is not high either. After just one round, the pregnancy rate is only 29 percent.
Insurance companies often cover infertility testing because it is cheaper. They want to know why you cannot conceive. They are less willing to pay for the actual treatment. If you live in a state without mandate, you may have to self-fund the process.
Is LASIK Surgery Covered by Insurance?
LASIK is considered elective or cosmetic. Like liposuction, it is not usually covered by standard health insurance. It corrects nearsightedness, farsightedness, and astigmatism.
If you have vision insurance, which is often an add-on to health insurance, you might have some coverage. But that usually extends to glasses or contact lenses. These are cheaper alternatives. Insurance companies prefer you wear lenses rather than undergo surgery.
There are two ways to potentially get coverage:
- Discounts: Most insurers have negotiated discounted rates with LASIK providers. You pay less, but it is still out of pocket.
- Medical Necessity: If you can prove LASIK is necessary for job performance, such as for military service, some insurers might pay. It is not guaranteed, but it is a possibility.
Understanding Drug Formularies
Every insurance company maintains a formulary. This is a list of drugs they cover and the tier at which they are placed.
Higher-tier drugs are technically covered. But they come with higher co-pays. Insurance companies frequently remove name-brand medications from their formularies if a generic option is available. They may also strike deals with competing medications.
If your insurance cuts your favorite prescription, you are left with two choices. Pay out of pocket. Or ask your physician to petition for an exemption. The latter takes time and effort. The former takes money.
The system is not designed to be simple. It is designed to manage costs for the insurer. Understanding these gaps is the only way to protect yourself. You are not just buying insurance. You are navigating a complex maze of exclusions and exceptions. One misstep can leave you with a bill you cannot pay. The question is not whether you understand your policy. The question is whether you understand what it does not cover.
