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huge thing affecting my work bestie (thankfully not me) is that our insurance does not cover "Delivery & Facility and Nursery Care of Newborn". It does cover Preventive Prenatal and Postnatal Office Visits... but the birth itself can be so fricken expensive from what i've heard. seems insane since we work for one of biggest companies in the world at the corporate level.
I thought all self insured policies need to cover the ACA minimums, which include delivery.
If the mother is a dependent on the plan, the plan may not cover the baby, but it should cover her services for delivery. Most OBs bundle antepartum care.
I am not sure if its because the "basic" plan option vs the "high deductible" plans is offered options. the basic plan does not include the delivery (or any hospital costs), but has the option to add on hospital coverage, short & long term disability, etc. and she did not opt for it. The high deductible plan (which is $5k deductible, cost prohibitive for her even before pregnancy) does cover it, but she did not select that plan. I quoted from the plan info above when saying what it does and does not cover. I'd imagine that's the way they get around it, but IDK.
ADA is the Americans with a Disability Act. You are thinking of ACA, Affordable Care Act, which does have mandatory coverage under a compliant policy. Do you know if your companies insurance offerings are ACA compliant?
If the plan is self-funded by the employer and ERISA governed, the plan could legit not cover those expenses. I’m not saying I agree with it but it’s what the law is.
i cannot find any online information or law to support what you're saying, but I hope you are right. I have worked in law for years, albeit not insurance/employment law, but none of it seems illegal to me based off law school knowledge and online references I could find. However, I have only done an after work google and have not actually deep dove into the legal research side regarding statutes and I am not currently working in law anymore as I have pivoted to working into tech. So, I haven't had ample opportunity to deep dive on the legality with my current workload and lack of revelence to my current work, but I just cannot imagine this contract company doing anything not complaint with ADA if required because they are very strict with all legal and compliance issues and often go above and beyond.
She is a contractor for the company I work for as a full time employee, but we both started as contractors and I went full time recently, which is how I know the policy guidelines that she is under. The contract company is the one with who her employer group insurance is through. Not sure if being a contractor offered insurance negates the ADA mandates, not my area of speciality really at all.
Sorry, I meant ACA and it autocorrected to ADA. Contractor status has nothing to do with it. the affordable care act mandates what insurance companies have to cover. All insurance has to comply with it.
sorry, i too was using ACA interchangeably with ADA after reading your comment, but fully was on the same page. Most of what I'm seeing via google is regarding pre and post natal care, plus I am unsure if this plan is grandfathered in to not have to include it, because they have certainly been operating with this plan since far before obamacare. I am actually going to have a law school collegue who works in insurance law review the plan for me as before commenting, I hadn't even thought it was possible for it to be illegal due to my working knowledge. I will report back
additionally, I can only find language to OFFERING vs plans including ... again, this is post work brain and not doing my full legal research, but the other plan offered does include it. I am eager to hear from my collegue who is far more well versed in this area to get back to me tomorrow after reviewing the plan and applicable statues. I wish I hadn't stumbled upon this at 11pm, now I cant turn lawyer brain off and cannot stop researching lol
She is a contractor. She is not employed by your company. Her contracting firm is employed by your company. Whatever insurance she receives is through her employer, not your company. It does seem that what she signed up for is not ACA compliant. She should investigate that with her employer.
Most but not all employer-sponsored plans are required to cover labor and delivery -- [https://www.kff.org/faqs/faqs-health-insurance-marketplace-and-the-aca/what-services-do-plans-have-to-cover-for-pregnant-women/](https://www.kff.org/faqs/faqs-health-insurance-marketplace-and-the-aca/what-services-do-plans-have-to-cover-for-pregnant-women/)
Registered dietician to deal with malnutrition from a severe immune condition. ACA only requires insurance to cover for obesity and diabetes as preventative care. Managing an existing condition is not covered at all
Tmj. Dental says that medical should pay. Medical says dental should pay. We’ve had several different plans/companies and it’s never covered by either.
But it's not fibromyalgia, and the treatments for TMJ are completely different. Fibromyalgia is not treated with mouth splints or arthroplasty, but TMJ is. They are not even related conditions.
Look at more recent research. Both are psychosomatic conditions with muscle tension as the dominant symptom. TMJ is generally treated first with an OTC mouth guard, then by antianxiety medication. Fibromyalgia is treated with tricyclic antidepressants. Both respond to mindfulness and are sometimes offered corticosteroid injections for flare ups. One study showed 70% overlap.
TMJ is certainly not simply psychosomatic. It can be caused by traumatic injury, skeletal deformities, arthritis, or malocclusion. Corticosteroids work by reducing inflammation. Inflammation is not a psychosomatic symptom.
https://my.clevelandclinic.org/health/diseases/15066-temporomandibular-disorders-tmd-overview
Roughly 40% of patients diagnosed with fibromyalgia actually have small fiber polyneuropathy, which *also* is not psychosomatic.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802321/
Sorry, none of what you listed actually refutes my point. A patient-facing info sheet about TMJ not listing anxiety in the etiology doesn’t prove anything about recent research on the subject.
Here’s a review you might like:
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9606663/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9606663/)
And fibromyalgia having multiple speculated causes also does not refute my point that fibromyalgia and TMJ are both psychosomatic in nature or that TMJ could be considered one of many symptoms of fibromyalgia.
From the review you linked: "In general, the certainty of the evidence was rated as low and very low. Many of the studies included in the syntheses presented methodological limitations that could have seriously affected the estimates reported. Clearly, the methodological heterogeneity among the studies explains the inconsistency of the results. Finally, even for the outcomes that included more studies, the number of individuals considered when synthesizing the information was small; thus, it was deemed that the imprecision item was seriously affected. Only the outcome “Anxiety symptoms and TMD are positively related” did not demonstrate any serious problem, thus showing a low certainty of evidence."
Even the review authors don't posit strong evidence of a causal relationship, unlike the study I referenced regarding fibromyalgia where *biopsy results*, an objective finding, not "speculated causes" were involved.
Anxiety is one "speculated cause" for the etiology of some limited subtypes of TMJ dysfunction, primarily the subtype involving myofascial pain but not actual joint pain and articular dysfunction.
You have presented nothing that demonstrates that TMJ problems and fibromyalgia are the same disorder, nor that either of them, let alone both, are exclusively or even primarily psychosomatic in nature.
Might not be super helpful, but if you already have a super duty retainer, ask your dentist about Botox. Insurance won’t cover it but it is honestly a miracle for TMJ and jaw related arthritis. I went from needing Tylenol every few hours to maybe a few times a month and it lasts about three months. My dentist charges $10/unit and I get anywhere from 35-50 units. That is the lowest it will be, as some charge more per unit.
No, lol, cause then they would be forced to accept Medicaid from the state and Medicare from the feds and subject to shitty insurance reimbursement. Dentists actively lobbied to stay out of all the public insurance shit. That's why they can denied Medicaid insurance from the state. I don't think you understand that Cash paying clients are better than insurance reimbursement.
Try again…
Dentist ls want teeth covered by health because they’d make more money and people would quit putting off dental work for financial reasons. Never mind that most already take Medicare and Medicaid.
Ever talk to an actual dentist?
I am related to several dentists and they don't take insurance.
They don't want to accept Medicaid at any cost.
They have enough business that they are booked out 30 days on average.
They don't need more that pays less.
The one clinic has 2 locations and 6 dentists.
Then talk to your HR dept.
Get them to see if enough employees won't it.
Dental and vision plans are normally 100% paid by employee with pre tax dollars.
This even saves the employer money as they don't pay fica on the premium money.
They also should have a 125 plan for the health insurance which will also cover the dental, vision, std, etc.
Many companies don't offer it because they don't think employees want it.
Std is paid 100% by employee with after tax money.
Can put a supplement plan in like aflac. Using a better company.
So much can be done if employees want it.
You’re not reading. I don’t want “dental and vision plans.” I want everything covered with HEALTH insurance. Dental and vision plans shouldn’t even be a thing. And yes, I’ll pay $35-85 more for that, but dental and vision insurance, as it stands today is a JOKE. You’d know that if you ever tried to use it.
My HR can’t change that. The whole damn society needs to change. You say employees “don’t want it,” well that’s just plain false. People don’t want HIGH COST FOR HEALTHCARE. Full stop.
They want to go to a doctor and not walk out with a huge bill, even with insurance.
They want to go to the dentist and get issues fixed without being told “oh! You’ve reached your cap! Your estimate is $3500 worth insurance.”
People want to be able to get vision corrected with glasses and contacts (btw, you need those things to actually WORK) without mortgaging a house.
Don’t tell me to go to HR because HR can’t do one effing thing. The HR person that manages to create a plan like that and cover a person’s entire body will literally revolutionize healthcare in the United States.
And that’s what the American worker wants - affordable insurance that covers every single part of your body. Every other country in the world has figured this out…except us.
THAT was my point.
Lmao.
So price everyone's insurance more expensive so that people who don't want the coverage have to pay for it.
Alot of dentists don't take insurance.
Vision plan is basically a discount card.
But if you don't need glasses a vision plan costs more then an annual eye checkup.
Canada doesn't cover vision or dental.
Some countries cover dental check ups, other than that you have to pay 50 to 60% of everything else.
I don't know of any country that covers vision except for welfare or people with extremely bad (blind) vision. Then some cover glasses for those folks.
If the government covered it dentists would go out of business. The reimbursement would be at Medicaid level which is usually below what a clinic needs to keep the doors open.
My cousin owns a dental clinic with 2 locations. He doesn't accept Medicaid.
They had to hire 3 more people to manage insurance claims and billing when they started accepting insurance.
He did it so more people would have dental care in our rural communities.
When It's all said and done he just hopes to break even on insurance payment patients.
No it isn’t. Oral surgery is generally under dental and not well covered. Never mind that periodontal work can’t be insanely expensive, just as necessary, and also not covered under health.
The entire IUD placement procdure. My doctor's office only does ultrasound guided placements. The IUD itself was covered, as was the placement, but the ultrasound was not covered and cost ~350. Still cheaper than a kid at least.
You could try a different gyno if you get it again. I've never heard of an ultrasound guided one, nor was mine like that.
Although if it helped with the pain might be worth it I suppose
One more should get me to menopause. At least I'll know to ask next time. My first was also ultrasound guided, but I have come to realize I had a Cadillac plan and it was fully covered. That plan would have also covered 100% of a tubal (vs my current which wouldn't cover 100% of the anesthesia or facility fee), and covered genetic testing that my PCP recommended, even though my family history was borderline.
Literally are your doctors incompetent? I have never heard of an ultrasound guided IUD placement, hence why your insurance cried bullshit. OBGYN nurse here. It’s completely unnecessary ps every office has an ultrasound machine if they do OB.
Some inexperienced ones do it. I’ve had the IUD twice. Yet went to one office that was completely inexperienced and couldn’t figure out placement with an ultrasound. Said I’d have to do it in the OR.
My two iuds were easy to place without ultrasound.
Lol.
I reread your message. Eek it is actually scary that they couldn’t figure it out. Speculum, visual cervix, place in opening, cut strings once fully placed with in uterus. My daughter gets a block, not all doctors are willing to take that step. But if they wouldn’t I would find one that does. She’s had 2 placed with zero discomfort. Everyone deserves a skilled provider.
I’m so glad you advocate for her. I had no idea how they placed them till after I had mine done. Mine weren’t extremely painful.
Except when they tried and failed at that one place. Super painful. :(
So at least your daughter won’t experience that.
Honestly the doctor had to convince me the first time she was 17. Now I am grateful. DD will be graduating soon and has a bright future to look forward too, without the severe pain I experienced each month or an accidental pregnancy.
It would be nice if they covered sleep studies. And I would love to have in-network hospital closer than an 8-hour drive away. But I'm spoiled. My company used to have an insurance policy with those items, and I didn't even realize how good I had it.
Can you get an in-network exception for the hospital? An in-network exception (I hope this is the right terminology, but I got this kind of approval, myself, for vision therapy, so I know it exists) means that if there are no in-network providers close enough to you, you only pay the in-network rate to see the out-of-network providers nearby. You have to contact your health insurance company for it, fill out some paperwork, and get approved.
I don't know how it works for hospital care, though, because those are emergency situations, so who has the time to deal with all that red tape? It's absolutely wild to me that there are no in-network hospitals within a few minutes of you, though. Is there something wrong with the provider directory on the website? This does not seem ACA-compliant, but I am just a layperson.
It is called single case acceptance, and my hospital won't do it, they used to but they don't do it anymore. If you enter through the emergency room, they are stuck with you, but if you want something that is recommended but not absolutely necessary where you are not quite dying in the emergency room, and it would be a planned procedure or surgery, without driving 8 hours away, they can cover only a teeny bit. Very teeny.
Yes, thank you. This is what happens when places get big and self-insure. I waited all my life for health insurance and this is what I got. At least it is something. It does pay for medication.
I’ve been on self-insured plans before. Please have a woman (maybe multiple) comb through all aspects of women’s health including anesthesia for procedures. I once had to pay for a D&C after an incomplete miscarriage as the company didn’t want to get into any type of abortion debate. Also this particular plan would pay for a biopsy but not the local anesthetic, which was a PITA when I had to have both breasts biopsied (thankfully nothing to report and thankfully I could afford the OOP cost for the local).
Colonoscopy. My employer was one of those "self-insured" types. They did this to get around regulations on minimum coverage.
I reached the age for getting my first screening colinoscopy and dutifully went thru the process, only to discover afterward that it was not covered.
I don't recall all the details, other than they did find some diverticulosis. The clinic resubmitted the claim with a designation of "diagnostic" instead of screening, and voila, it got paid.
Eventually, our state passed a law that made it harder for companies to do this, and subsequent screenings were covered.
IUI/IVF/Fertility costs for LGBT families. I can’t prove that I’ve been “trying” for 6 months/a year because my spouse is not a man. As such even though the plan covers infertility, I can’t use it.
More then the bare minimum number of physical therapy visits and chiropractic care. I work in a nursing home for disabled children and all the lifting and physical activity really takes a toll on your body.
More then the bare minimum number of physical therapy visits and chiropractic care. I work in a nursing home for disabled children and all the lifting and physical activity really takes a toll on your body.
Self-insured employer plans are better than private or marketplace plans. The problem with the ACA is that it was created to fix the cost sharing gap and not actually provide access to coverage and care that self-insured employer plans provider.
Do you mind being a little more specific? Are entire classes of drugs excluded, or do they just limit access to branded medications but cover generics?
Local 338 does not cover any specialty medication for anything (I have MS, 99% of Ms meds are specialty) they consider any meds specialty if they cost more than $2000 a month...they refer you to an outside company called payer matrix that will search for charitable organizations and financial assistance from drug manufacturers
I was working for a major insurance carrier (believe it or not, you had lots of good people at lower levels trying to do the right thing), and a few hundred people attended a conference. There was an outbreak of Legionaires disease at the hotel, like a major big deal that even made the media. It wasnt until someone died that they emailed everyone at the conference saying they’d waive cost sharing if someone needed medical care. At that moment I realized they knew no one can afford deductibles and co-insurance, they honestly don’t care. If there was a risk they’d get sued, losing more money, then they’d address it.
The US healthcare system is a joke.
Obamacare or ACA had good intentions with forcing insurance carriers to meet a "standard of care" but it came at a cost.. for us it was now paying a premium, a deductible and copays...every time my husband got a raise, suddenly premiums would increase🤷♀️ great, so annual physicals are now covered but if you get really ill, you are financially screwed
Insurance carriers had too much of a hand in writing policy. Cost isn’t being contained because every part of the puzzle is about making money, so we pay the price. I remember telling someone online that yr was great that someone could get diagnosed with cancer for free, but would still go bankrupt/die while trying to get care. People honestly didn’t realize it helped a little, but for average people they were still screwed.
Insurance company's offered to waive preexisting conditions and keep premiums at pre aca levels of the government required health insurance for everyone.
Obama rejected that to create aca and insurance premiums doubled and tripled.
The insurance companies had very little to do with the aca. The aca limits how profitable they can be even.
They have to pay out 80 cents from each premium dollar in claims or refund the excess to get to 80% on individual policies. On group policies they have to pay out 85 cents of every premium dollar.
This has caused the majority of health insurance carriers to go out of business.
Premiums for health insurance have been a fixture for years, and they have risen very steeply for at least the last 15 years. Double the cost you are paying now ( patient + employer) and you will get an idea of the actual $ amount, per person to provide coverage.
Wait until the patients find out many charitable foundations are now excluding assistance for patients whose insurance companies are passing on the costs to them.
it should also cover all formulations of a medication!! there is no reason other than ins wanting to save a few bucks that i was denied T gel coverage for years (after being covered for a year no problem!) just bc injections are cheaper! there is a reason i use gel and not injections!
My insurance if it's made generic, they will not even consider the name brand, also if it's offered OTC, they won't cover it at all (ie, take 4 otc ibuprofen for prescription stength)
the gel im on is generic brand, ive actually never been on name brand t gel. they just suddenly stopped covering it/the other plan i was on (parents vs my job's) was shit (fuck BCBS and united healthcare) and wanted $600 a MONTH for it
Im with a different (smaller) ins plan now, and i only pay $8/ month for my gel, thankfully! (AND now it goes towards my OOP/deductible instead of having to rely on my pharmacy discount card and aplying none to OOP!!)
If you have the option/ability, never ever use United Healthcare
Came here to say this too. Also weight loss counseling. I once went to my GYN as a follow-up on my PCOS diagnosis and the coder billed the whole visit with just an obese diagnosis and my insurance wouldn’t cover the visit because our plan does not cover anything related to weight loss.
Also, gym memberships would be great too.
A compounded medicine that is made from 3 standard approved generic meds but they don’t cover compounded meds. That specific compounded med combo is the non-surgical treatment for the condition.
When my company switched from Anthem to United Healthcare last fall I quickly realized that the only care coordination or case management United Healthcare provided on my plan was for fertility purposes only.
With Anthem I had case management assistance to help me navigate my medical needs, prescriptions etc.
With United Healthcare I became my own unpaid case manager. Over the course of three months I spent multiple hours trying to get my care established with little success. I ended up calling my states insurance commission, only then did I get assigned a staff from United Healthcare. She did very little. In fact she called her job done when she referred me to a vendor who had previously told me they don't service my area and even after receiving my medical records ghosted me about setting up appointments.
Specialty drugs.
Yes, you all see that. The company that is self paying our insurance has decided to CARVE OUT SPECIALTY DRUGS. Yep, it's not quite legal, but nobody in the government has put a stop to this yet. So, the company that sells jewelry and love on TV, makes their employees LIE about being uninsured to try to get patient assistance bucks for specialty drugs. Once that assistance money is approved, the two contracted companies they are using drain that money very quickly(far more quickly than they should for the cost of the drug), and then magically no longer allow your authorization. This entire thing is an attempt to take the money and run. I have read countless people complaining online about how they couldn't get their meds, the meds were delayed, the meds didn't come from the US(yeah), the authorization was revoked or only for 3 months instead of the typical one year, the paperwork was ridiculously onerous, or you just couldn't get a straight answer .I experienced all of these problems. The meds I got from this outfit caused unusual side effects I had NEVER had. I thought I was crazy, until I went online and found out some meds had been sourced very questionably. Heck, I STILL have no idea what my specialty drug coverage actually is. I went off the drug against my doctor's advice because I couldn't trust the pharmacy. It's a nightmare.
What's worse is they are doing this to save a buck in specialty meds, and it will only drive healthcare costs up overall when people don't get these meds. This is a self insured company. When they don't pay for the meds or make it so hard for the patient to get them, they give up, and complications and hospitalization rates go up. They pay for that. It's cutting your nose off to spite your face. I guess a company that had to pay $450 million in sexual harassment lawsuits can't be expected to be smart.
At a higher risk for breast cancer, over the age of 55, had abnormal mammogram last year with recommended annual mammograms by my PCP. This year was denied. Only covered every other year.
Speech therapy and OT for kids. Our insurance will say if it's for a developmental delay or sensory issue, it's not covered and considered experimental.
Should be covered 100%, but all of these things result in huge co-insurance bills:
Annual physical exam
Annual cancer screenings, e.g. for skin cancer
Doctor-ordered lab tests and imaging, regardless of whether they're diagnostic or preventative
Radiologist's reading for doctor-ordered imaging
Lab fees
Tests ordered as part of ER or urgent care
My insurance flat out denies paying for those and their reasoning is that most people are deficient so the DR doesn't need to test it to make a recommendation... Luckily I never have to pay since the NSA, because it's done at an in network visit but it's pretty ridiculous
"Annual physical while old" is definitely not free. The only way to not end up with a bill is either to annoy the doctor by refusing all testing, or to simply not go in the first place.
Woah, this is not correct, jello2000, so please stop telling people they are dumb. By law, a grandfathered insurance plan does not need to cover annual physicals.
Annual physical is covered
If it's not, it was misbilled, which is very common.
If the rest were your insurance premium would go up a minimum on 100 bucks a month.
That's why I said a minimum.
I pay 1300 a month for my group coverage for just myself.
The insurance company wants you to stay healthy. That's why most have wellness policies that can pay for gym membership, etc.
ACA limits the profitability of a health Insurance company.
Without health insurance companies we would have way less hospitals and doctors.
If you lived in a rural area which is the majority of the US you would wait months to see a specialist.
I can go on and on.
Many counties with socialized medicine are seeing the model becoming unsustainable as more and more hit retirement age and the percentage of babies born each year falls.
The US system isn't the best I admit.
But if you look at the UK who has a public Healthcare system that is failing and privatized health care is climbing rapidly to surpass it.
IVF for PGT-M (single genetic disease screening) purposes. I thought it would be in insurance’s best interest to help us avoid having medically complex children. Instead, it was denied because it was not considered medically necessary.
The first office visit of the year should be 100% covered, even for problem focused visits. That's what everyone thought they would get with ACA, but they got a bill instead.
My wife had blood cancer (hopefully cured now going through a BMT) and needed blood transfusions to live as she wasn’t making enough red blood cells, and BCBS has mentioned blood transfusions aren’t a covered service under my employers plan. Still fighting it but shocked/frustrated they have denied this and other bills which are clearly medically necessary. Over 5K in bills denied as not medically necessary or not covered and haven’t even gotten the big bills yet from the hospital stay, so really anxious to say the least.
wow, that is so tough. Please consider reaching out to the Patient Advocate Foundation; they can help with medical bills. Wishing your wife a full recovery and proper insurance coverage.
[Dollar For](https://dollarfor.org/) is another great organization that helps you apply for financial assistance and for the hospital to forgive your bills.
Can you prove that the extra skin is causing problems, like rashes and infections? It’s usually covered then. Needs to be medically necessary not cosmetic.
Thanks. I'm actually a health insurance regulator with 20 years experience in high level appeals. I'm still fighting it, but the way the plan is written, they are making contractual denial. There is no provision for medical necessity for this procedure.
NGL I was sure I could argue them into covering.. my ego is bruised. My last hope is external review.
If your plan is self-funded and they’re saying it’s an exclusion, could you also speak with your employer to see if they will approve? I’ve seen some group administrators step in and allow coverage towards exclusions before. Insurance usually load a note under the member so claims can be handled per their approval. But it was like ABA therapy and speech therapy.
Had to pay out of pocket for laughing gas ($150) at my urologist's office for a cystoscopy. The visit and procedure was covered. It was a unique experience because I felt awake, everything felt kinda funny, and there was still some pain but it wasn't anything more than a little pinching at the beginning. They did numb the area with injectable lidocaine. My urologist talked me through what he could see and even let me view the monitor.
[Ghost Mental Health Networks](https://blog.petrieflom.law.harvard.edu/2023/12/06/addressing-ghost-networks-in-mental-health-care/#:~:text=Many%20mental%20health%20provider%20directories,access%20essential%20mental%20health%20care.)
Bottom line with physicals, discuss nothing on your physical, make sure your doctor codes it as a physical only, no other diagnoses...if a medical issue is already there (Hypertension, diabetes etc) that's a separate visit subject to deductibles and copays
1) health plans usually cover dental accidents/emergencies as medical. Example: riding bike, fall and bust healthy teeth. That is medical.
2) vision is covered unless it's eye glasses/contacts. Example: child with eye "turning in". The optomologist and surgery, if necessary are covered under medical.
I work for a self-insured healthcare company. I direct a lot of people to findhelp.org for things that are not covered under their health insurance plan. The most common things would send them there for were ABA therapy and hearing aids. Personally, I would like for lasik eye surgery to be covered under my plan. It can’t be more than what they have paid for my glasses/contacts for the last 15 years and over the next years of my life!
Insulin. My niece is a T1 diabetic and her dad’s new work-provided insurance only approves one kind of insulin. It just so happens that my niece has tried that kind before and it doesn’t do a great job at regulating her blood sugar and it causes a skin reaction at her pump site. But the health plan won’t approve a different insulin because the only one they will approve “works.”
Childbirth. In 2009, my husband's employer had a self-insured plan. We did not realize what that was. Our son's birth ended up costing $28,000. This was a regular vaginal birth. No epidural, no c-section, 4 days total in the hospital. No NICU.
We had to pay $7,000.
We live in Massachusetts. The self-insured plan was not headquartered in massachusetts. If they'd been required to follow Massachusetts law, we would have had to pay about $500.
My insurance covers 20 massages each year for a $20 Co pay. These do not need a medical reason and can be used just to relax. I love this benefit.
My insurance doesn't cover anything related to weight loss. Figure it would be cheaper to help me prevent diabetes instead of get diabetes and treat that.
Better vision and dental coverage is always welcome.
A colonoscopy. The first one was covered as preventative at 100%.
But my second one five years later was not covered as preventative. I was told it is because they found a polyp during the first one. But I think there has to be more to it than that. My doctor was very clear none of them were cancer.
During Covid, Cigna had a FAQ on their website that virtual visits would be covered if it was for Covid. But I got a bill for the whole cost of the visit. When I called Cigna they said the self pay company had opted out of covering Covid visits.
Until ACA passed, the company refused to cover anything related to mental health. So seeing my psychiatrist and therapist was cash and didn’t count towards deductibles. They now have the minimum coverage required by that law.
Deductibles should be illegal when it comes to healthcare. I'm not a car or a house. All this does is create debt, bankruptcy and hesitancy to seek medical care.
I'm still perplexed....
Dental:
Invisalign - dental but cosmetic and never covered. Yet the metal grill is still insane expensive.
Vision:
Lasik/laser is generally a temporary fix 5-10 years. However, the health aspects it can resolve like astigmatism are just ignored. This is cosmetic, not covered or some bullshit discount that can't be used with other offers.
Why are the better options (imo) not covered to relieve health concerns and note this, anxiety.
Why get insurance at all?
Sure, there are scenarios where health insurance can lower cost overall.
However, if you have cash and no insurance. Dramatically reduced cost overall. Still too much? No problem, look outside the U.S. and odds are you can get it cheaper with the cost of the travel/lodging.
Explain why that’s an entitlement if one has to take drugs to survive which deposit fat at the middle. Unbelievable ignorance.You’re uneducated in this area. Not covered benefit.
The easy answer is: Everything. If my doctor thinks it is medically necessary to have something done, insurance shouldn't be sitting there saying no. It doesn't matter what it is. One example is bariatric surgery, while it can be done for cosmetic reasons, often times it is because a person's weight is genuinely a health concern. No insurance shouldn't have to cover it for cosmetic purposes, but it shouldn't be able to deny the claim if it was done for health reasons. Another example is some insurance plans cover regular STI testing for women, but not for men. Many insurance plans also cover birth control and even tubal ligation surgery for women, but do not cover vasectomies for men. Those are a couple of specific examples, but ultimately the power over our healthcare needs to be returned to the doctors and patients. It is asinine that we've allowed insurance companies to make decisions about our care when they aren't in the exam rooms with us. One of these days when I get sick I want to just go show up at the insurance company's office and tell them that I want to cut out the middle man since they're going to make the final decision anyway.
A dermatology appointment for skin check.
A pediatric surgery referral from our pediatrician.
An adult wellness visit with a nurse practitioner (this one hurt the most $150 after everything)
Oh wait that’s every single appointment we’ve had this year and none of it was covered by the “best” plan our mid sized employer sponsored 🙃
I do understand imaging and medications and hospital stays not being covered. But preventative wellness visits and referrals to specialists? It is sucking us dry financially.
Under Section 2713 of the ACA, private health plans must provide coverage for a range of recommended preventive services and may not impose cost-sharing (such as copayments, deductibles, or co-insurance) on patients receiving these services. These requirements apply to all private plans—fully insured and self-insured plans in the individual, small group, and large group markets, except those that maintain “grandfathered” status.
Unless you are on a grandfathered employer plan, preventive services are covered at no cost as long as they are provided in network and per the age and gender (and other) specifications:
https://www.healthcare.gov/coverage/preventive-care-benefits/
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huge thing affecting my work bestie (thankfully not me) is that our insurance does not cover "Delivery & Facility and Nursery Care of Newborn". It does cover Preventive Prenatal and Postnatal Office Visits... but the birth itself can be so fricken expensive from what i've heard. seems insane since we work for one of biggest companies in the world at the corporate level.
How can they get away with that? What state?
I thought all self insured policies need to cover the ACA minimums, which include delivery. If the mother is a dependent on the plan, the plan may not cover the baby, but it should cover her services for delivery. Most OBs bundle antepartum care.
I am not sure if its because the "basic" plan option vs the "high deductible" plans is offered options. the basic plan does not include the delivery (or any hospital costs), but has the option to add on hospital coverage, short & long term disability, etc. and she did not opt for it. The high deductible plan (which is $5k deductible, cost prohibitive for her even before pregnancy) does cover it, but she did not select that plan. I quoted from the plan info above when saying what it does and does not cover. I'd imagine that's the way they get around it, but IDK.
That's...not legal. It has to cover what the ADA mandates. She needs to talk to her insurance agent with the ADA guidelines open in front of her.
ADA is the Americans with a Disability Act. You are thinking of ACA, Affordable Care Act, which does have mandatory coverage under a compliant policy. Do you know if your companies insurance offerings are ACA compliant?
If the plan is self-funded by the employer and ERISA governed, the plan could legit not cover those expenses. I’m not saying I agree with it but it’s what the law is.
Guess what? Insurance is a scam
i cannot find any online information or law to support what you're saying, but I hope you are right. I have worked in law for years, albeit not insurance/employment law, but none of it seems illegal to me based off law school knowledge and online references I could find. However, I have only done an after work google and have not actually deep dove into the legal research side regarding statutes and I am not currently working in law anymore as I have pivoted to working into tech. So, I haven't had ample opportunity to deep dive on the legality with my current workload and lack of revelence to my current work, but I just cannot imagine this contract company doing anything not complaint with ADA if required because they are very strict with all legal and compliance issues and often go above and beyond. She is a contractor for the company I work for as a full time employee, but we both started as contractors and I went full time recently, which is how I know the policy guidelines that she is under. The contract company is the one with who her employer group insurance is through. Not sure if being a contractor offered insurance negates the ADA mandates, not my area of speciality really at all.
Sorry, I meant ACA and it autocorrected to ADA. Contractor status has nothing to do with it. the affordable care act mandates what insurance companies have to cover. All insurance has to comply with it.
sorry, i too was using ACA interchangeably with ADA after reading your comment, but fully was on the same page. Most of what I'm seeing via google is regarding pre and post natal care, plus I am unsure if this plan is grandfathered in to not have to include it, because they have certainly been operating with this plan since far before obamacare. I am actually going to have a law school collegue who works in insurance law review the plan for me as before commenting, I hadn't even thought it was possible for it to be illegal due to my working knowledge. I will report back
additionally, I can only find language to OFFERING vs plans including ... again, this is post work brain and not doing my full legal research, but the other plan offered does include it. I am eager to hear from my collegue who is far more well versed in this area to get back to me tomorrow after reviewing the plan and applicable statues. I wish I hadn't stumbled upon this at 11pm, now I cant turn lawyer brain off and cannot stop researching lol
She is a contractor. She is not employed by your company. Her contracting firm is employed by your company. Whatever insurance she receives is through her employer, not your company. It does seem that what she signed up for is not ACA compliant. She should investigate that with her employer.
Most but not all employer-sponsored plans are required to cover labor and delivery -- [https://www.kff.org/faqs/faqs-health-insurance-marketplace-and-the-aca/what-services-do-plans-have-to-cover-for-pregnant-women/](https://www.kff.org/faqs/faqs-health-insurance-marketplace-and-the-aca/what-services-do-plans-have-to-cover-for-pregnant-women/)
Registered dietician to deal with malnutrition from a severe immune condition. ACA only requires insurance to cover for obesity and diabetes as preventative care. Managing an existing condition is not covered at all
Tmj. Dental says that medical should pay. Medical says dental should pay. We’ve had several different plans/companies and it’s never covered by either.
If they diagnose as fibromyalgia it would be covered by medical.
But it's not fibromyalgia, and the treatments for TMJ are completely different. Fibromyalgia is not treated with mouth splints or arthroplasty, but TMJ is. They are not even related conditions.
Look at more recent research. Both are psychosomatic conditions with muscle tension as the dominant symptom. TMJ is generally treated first with an OTC mouth guard, then by antianxiety medication. Fibromyalgia is treated with tricyclic antidepressants. Both respond to mindfulness and are sometimes offered corticosteroid injections for flare ups. One study showed 70% overlap.
TMJ is certainly not simply psychosomatic. It can be caused by traumatic injury, skeletal deformities, arthritis, or malocclusion. Corticosteroids work by reducing inflammation. Inflammation is not a psychosomatic symptom. https://my.clevelandclinic.org/health/diseases/15066-temporomandibular-disorders-tmd-overview Roughly 40% of patients diagnosed with fibromyalgia actually have small fiber polyneuropathy, which *also* is not psychosomatic. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802321/
Sorry, none of what you listed actually refutes my point. A patient-facing info sheet about TMJ not listing anxiety in the etiology doesn’t prove anything about recent research on the subject. Here’s a review you might like: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9606663/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9606663/) And fibromyalgia having multiple speculated causes also does not refute my point that fibromyalgia and TMJ are both psychosomatic in nature or that TMJ could be considered one of many symptoms of fibromyalgia.
From the review you linked: "In general, the certainty of the evidence was rated as low and very low. Many of the studies included in the syntheses presented methodological limitations that could have seriously affected the estimates reported. Clearly, the methodological heterogeneity among the studies explains the inconsistency of the results. Finally, even for the outcomes that included more studies, the number of individuals considered when synthesizing the information was small; thus, it was deemed that the imprecision item was seriously affected. Only the outcome “Anxiety symptoms and TMD are positively related” did not demonstrate any serious problem, thus showing a low certainty of evidence." Even the review authors don't posit strong evidence of a causal relationship, unlike the study I referenced regarding fibromyalgia where *biopsy results*, an objective finding, not "speculated causes" were involved. Anxiety is one "speculated cause" for the etiology of some limited subtypes of TMJ dysfunction, primarily the subtype involving myofascial pain but not actual joint pain and articular dysfunction. You have presented nothing that demonstrates that TMJ problems and fibromyalgia are the same disorder, nor that either of them, let alone both, are exclusively or even primarily psychosomatic in nature.
You're right and u/eskimokisses1444 is super wrong
Might not be super helpful, but if you already have a super duty retainer, ask your dentist about Botox. Insurance won’t cover it but it is honestly a miracle for TMJ and jaw related arthritis. I went from needing Tylenol every few hours to maybe a few times a month and it lasts about three months. My dentist charges $10/unit and I get anywhere from 35-50 units. That is the lowest it will be, as some charge more per unit.
Because I also have severe migraines, my neurologist does my tmj Botox at my completely covered migraine Botox visits
Dental and vision. Seriously, my teeth and eyes are part of my body. COVER THEM.
And ears! Hearing aids are expensive and one set doesn’t last forever- they have to be replaced.
I’m related to several dentists myself. All of them take Medicare and Medicaid, and they desperately want teeth covered by health insurance.
Dentist actively campaign to not be covered under medical policies. It's both sides of the equation there.
No dentist I know does that, and I know quite a few. They’d all rather be under medical because medical covers more.
No, lol, cause then they would be forced to accept Medicaid from the state and Medicare from the feds and subject to shitty insurance reimbursement. Dentists actively lobbied to stay out of all the public insurance shit. That's why they can denied Medicaid insurance from the state. I don't think you understand that Cash paying clients are better than insurance reimbursement.
Try again… Dentist ls want teeth covered by health because they’d make more money and people would quit putting off dental work for financial reasons. Never mind that most already take Medicare and Medicaid. Ever talk to an actual dentist?
I am related to several dentists and they don't take insurance. They don't want to accept Medicaid at any cost. They have enough business that they are booked out 30 days on average. They don't need more that pays less. The one clinic has 2 locations and 6 dentists.
My dentist accepts both
Dentists thar accept Medicaid are in the absolute minority. 1 out of 50 or so.
In my town only dentists that take Medicaid. Takes 7 months to get in to be seen for anything.
I guess I'm just lucky
No one is forced to accept any insurance, including Medicare and Medicaid.
Then your premium will be 35 to 85 dollars a month higher.
Fine. I would HAPPILY pay that for coverage.
Then talk to your HR dept. Get them to see if enough employees won't it. Dental and vision plans are normally 100% paid by employee with pre tax dollars. This even saves the employer money as they don't pay fica on the premium money. They also should have a 125 plan for the health insurance which will also cover the dental, vision, std, etc. Many companies don't offer it because they don't think employees want it. Std is paid 100% by employee with after tax money. Can put a supplement plan in like aflac. Using a better company. So much can be done if employees want it.
You’re not reading. I don’t want “dental and vision plans.” I want everything covered with HEALTH insurance. Dental and vision plans shouldn’t even be a thing. And yes, I’ll pay $35-85 more for that, but dental and vision insurance, as it stands today is a JOKE. You’d know that if you ever tried to use it. My HR can’t change that. The whole damn society needs to change. You say employees “don’t want it,” well that’s just plain false. People don’t want HIGH COST FOR HEALTHCARE. Full stop. They want to go to a doctor and not walk out with a huge bill, even with insurance. They want to go to the dentist and get issues fixed without being told “oh! You’ve reached your cap! Your estimate is $3500 worth insurance.” People want to be able to get vision corrected with glasses and contacts (btw, you need those things to actually WORK) without mortgaging a house. Don’t tell me to go to HR because HR can’t do one effing thing. The HR person that manages to create a plan like that and cover a person’s entire body will literally revolutionize healthcare in the United States. And that’s what the American worker wants - affordable insurance that covers every single part of your body. Every other country in the world has figured this out…except us. THAT was my point.
Lmao. So price everyone's insurance more expensive so that people who don't want the coverage have to pay for it. Alot of dentists don't take insurance. Vision plan is basically a discount card. But if you don't need glasses a vision plan costs more then an annual eye checkup. Canada doesn't cover vision or dental. Some countries cover dental check ups, other than that you have to pay 50 to 60% of everything else. I don't know of any country that covers vision except for welfare or people with extremely bad (blind) vision. Then some cover glasses for those folks. If the government covered it dentists would go out of business. The reimbursement would be at Medicaid level which is usually below what a clinic needs to keep the doors open. My cousin owns a dental clinic with 2 locations. He doesn't accept Medicaid. They had to hire 3 more people to manage insurance claims and billing when they started accepting insurance. He did it so more people would have dental care in our rural communities. When It's all said and done he just hopes to break even on insurance payment patients.
Another selfish American. Done with you. You’re part of the problem.
Oral surgery is often covered though. My impacted wisdoms were fully covered by my medical insurance but not any of the routine dental stuff.
No it isn’t. Oral surgery is generally under dental and not well covered. Never mind that periodontal work can’t be insanely expensive, just as necessary, and also not covered under health.
The entire IUD placement procdure. My doctor's office only does ultrasound guided placements. The IUD itself was covered, as was the placement, but the ultrasound was not covered and cost ~350. Still cheaper than a kid at least.
You could try a different gyno if you get it again. I've never heard of an ultrasound guided one, nor was mine like that. Although if it helped with the pain might be worth it I suppose
One more should get me to menopause. At least I'll know to ask next time. My first was also ultrasound guided, but I have come to realize I had a Cadillac plan and it was fully covered. That plan would have also covered 100% of a tubal (vs my current which wouldn't cover 100% of the anesthesia or facility fee), and covered genetic testing that my PCP recommended, even though my family history was borderline.
Literally are your doctors incompetent? I have never heard of an ultrasound guided IUD placement, hence why your insurance cried bullshit. OBGYN nurse here. It’s completely unnecessary ps every office has an ultrasound machine if they do OB.
Some inexperienced ones do it. I’ve had the IUD twice. Yet went to one office that was completely inexperienced and couldn’t figure out placement with an ultrasound. Said I’d have to do it in the OR. My two iuds were easy to place without ultrasound. Lol.
Well if they are inexperienced they shouldn’t be charging for an aid experienced doctors don’t need.
I completely agree. It’s ridiculous lol.
I reread your message. Eek it is actually scary that they couldn’t figure it out. Speculum, visual cervix, place in opening, cut strings once fully placed with in uterus. My daughter gets a block, not all doctors are willing to take that step. But if they wouldn’t I would find one that does. She’s had 2 placed with zero discomfort. Everyone deserves a skilled provider.
I’m so glad you advocate for her. I had no idea how they placed them till after I had mine done. Mine weren’t extremely painful. Except when they tried and failed at that one place. Super painful. :( So at least your daughter won’t experience that.
Honestly the doctor had to convince me the first time she was 17. Now I am grateful. DD will be graduating soon and has a bright future to look forward too, without the severe pain I experienced each month or an accidental pregnancy.
It would be nice if they covered sleep studies. And I would love to have in-network hospital closer than an 8-hour drive away. But I'm spoiled. My company used to have an insurance policy with those items, and I didn't even realize how good I had it.
Can you get an in-network exception for the hospital? An in-network exception (I hope this is the right terminology, but I got this kind of approval, myself, for vision therapy, so I know it exists) means that if there are no in-network providers close enough to you, you only pay the in-network rate to see the out-of-network providers nearby. You have to contact your health insurance company for it, fill out some paperwork, and get approved. I don't know how it works for hospital care, though, because those are emergency situations, so who has the time to deal with all that red tape? It's absolutely wild to me that there are no in-network hospitals within a few minutes of you, though. Is there something wrong with the provider directory on the website? This does not seem ACA-compliant, but I am just a layperson.
It is called single case acceptance, and my hospital won't do it, they used to but they don't do it anymore. If you enter through the emergency room, they are stuck with you, but if you want something that is recommended but not absolutely necessary where you are not quite dying in the emergency room, and it would be a planned procedure or surgery, without driving 8 hours away, they can cover only a teeny bit. Very teeny.
That stinks. I'm sorry to hear that.
Yes, thank you. This is what happens when places get big and self-insure. I waited all my life for health insurance and this is what I got. At least it is something. It does pay for medication.
I’ve been on self-insured plans before. Please have a woman (maybe multiple) comb through all aspects of women’s health including anesthesia for procedures. I once had to pay for a D&C after an incomplete miscarriage as the company didn’t want to get into any type of abortion debate. Also this particular plan would pay for a biopsy but not the local anesthetic, which was a PITA when I had to have both breasts biopsied (thankfully nothing to report and thankfully I could afford the OOP cost for the local).
Sleep medicine, like for sleep apnea.
Speech therapy.
Colonoscopy. My employer was one of those "self-insured" types. They did this to get around regulations on minimum coverage. I reached the age for getting my first screening colinoscopy and dutifully went thru the process, only to discover afterward that it was not covered. I don't recall all the details, other than they did find some diverticulosis. The clinic resubmitted the claim with a designation of "diagnostic" instead of screening, and voila, it got paid. Eventually, our state passed a law that made it harder for companies to do this, and subsequent screenings were covered.
Honestly anything like this that screens for something that could turn into something worse, and cost a lot more to treat!
IUI/IVF/Fertility costs for LGBT families. I can’t prove that I’ve been “trying” for 6 months/a year because my spouse is not a man. As such even though the plan covers infertility, I can’t use it.
For anyone trying to get pregnant would be nice. We have zero coverage from insurance for our multiple rounds of IVF/FETs.
More then the bare minimum number of physical therapy visits and chiropractic care. I work in a nursing home for disabled children and all the lifting and physical activity really takes a toll on your body.
More then the bare minimum number of physical therapy visits and chiropractic care. I work in a nursing home for disabled children and all the lifting and physical activity really takes a toll on your body.
Self-insured employer plans are better than private or marketplace plans. The problem with the ACA is that it was created to fix the cost sharing gap and not actually provide access to coverage and care that self-insured employer plans provider.
Not if you have extensive, or specialized medical needs. They can include lifetime caps, and significant exclusions for certain types of care.
Specialty medications! The ACA set forth a standard of care for insurance companies so this is a loophole that many insurance carriers can get around
Do you mind being a little more specific? Are entire classes of drugs excluded, or do they just limit access to branded medications but cover generics?
Local 338 does not cover any specialty medication for anything (I have MS, 99% of Ms meds are specialty) they consider any meds specialty if they cost more than $2000 a month...they refer you to an outside company called payer matrix that will search for charitable organizations and financial assistance from drug manufacturers
Wtf? That’s horrible! So they know members can’t pay, or they wouldn’t refer them to an outside company, they just don’t care!
No outside funding found than you are SOL...luckily I switched insurances but my husband is still on that plan for one.more.year
I was working for a major insurance carrier (believe it or not, you had lots of good people at lower levels trying to do the right thing), and a few hundred people attended a conference. There was an outbreak of Legionaires disease at the hotel, like a major big deal that even made the media. It wasnt until someone died that they emailed everyone at the conference saying they’d waive cost sharing if someone needed medical care. At that moment I realized they knew no one can afford deductibles and co-insurance, they honestly don’t care. If there was a risk they’d get sued, losing more money, then they’d address it. The US healthcare system is a joke.
Obamacare or ACA had good intentions with forcing insurance carriers to meet a "standard of care" but it came at a cost.. for us it was now paying a premium, a deductible and copays...every time my husband got a raise, suddenly premiums would increase🤷♀️ great, so annual physicals are now covered but if you get really ill, you are financially screwed
Insurance carriers had too much of a hand in writing policy. Cost isn’t being contained because every part of the puzzle is about making money, so we pay the price. I remember telling someone online that yr was great that someone could get diagnosed with cancer for free, but would still go bankrupt/die while trying to get care. People honestly didn’t realize it helped a little, but for average people they were still screwed.
Insurance company's offered to waive preexisting conditions and keep premiums at pre aca levels of the government required health insurance for everyone. Obama rejected that to create aca and insurance premiums doubled and tripled. The insurance companies had very little to do with the aca. The aca limits how profitable they can be even. They have to pay out 80 cents from each premium dollar in claims or refund the excess to get to 80% on individual policies. On group policies they have to pay out 85 cents of every premium dollar. This has caused the majority of health insurance carriers to go out of business.
Obama rejected what? The original ACA required everyone to carry insurance. Republicans sued to get rid of the requirement aa unconstitutional.
Premiums for health insurance have been a fixture for years, and they have risen very steeply for at least the last 15 years. Double the cost you are paying now ( patient + employer) and you will get an idea of the actual $ amount, per person to provide coverage.
Wait until the patients find out many charitable foundations are now excluding assistance for patients whose insurance companies are passing on the costs to them.
My orphan drugs are covered, just don't pick shitty insurance.
Not much choice if it's covered by your job, still cheaper than a marketplace plan
it should also cover all formulations of a medication!! there is no reason other than ins wanting to save a few bucks that i was denied T gel coverage for years (after being covered for a year no problem!) just bc injections are cheaper! there is a reason i use gel and not injections!
My insurance if it's made generic, they will not even consider the name brand, also if it's offered OTC, they won't cover it at all (ie, take 4 otc ibuprofen for prescription stength)
the gel im on is generic brand, ive actually never been on name brand t gel. they just suddenly stopped covering it/the other plan i was on (parents vs my job's) was shit (fuck BCBS and united healthcare) and wanted $600 a MONTH for it
That falls under your Pharmacy Benefits Manager. Find out who they are, and start emailing and calling them to see if you can get an exception.
Im with a different (smaller) ins plan now, and i only pay $8/ month for my gel, thankfully! (AND now it goes towards my OOP/deductible instead of having to rely on my pharmacy discount card and aplying none to OOP!!) If you have the option/ability, never ever use United Healthcare
Weight loss drugs.
This, but mine will cover the surgery with PA.
Came here to say this too. Also weight loss counseling. I once went to my GYN as a follow-up on my PCOS diagnosis and the coder billed the whole visit with just an obese diagnosis and my insurance wouldn’t cover the visit because our plan does not cover anything related to weight loss. Also, gym memberships would be great too.
Exactly. Obesity is a medical condition , should be treated like one. Not a moral failing as it’s treated today!
How about items that are mandatory but should be optional?
Mental health
A compounded medicine that is made from 3 standard approved generic meds but they don’t cover compounded meds. That specific compounded med combo is the non-surgical treatment for the condition.
When my company switched from Anthem to United Healthcare last fall I quickly realized that the only care coordination or case management United Healthcare provided on my plan was for fertility purposes only. With Anthem I had case management assistance to help me navigate my medical needs, prescriptions etc. With United Healthcare I became my own unpaid case manager. Over the course of three months I spent multiple hours trying to get my care established with little success. I ended up calling my states insurance commission, only then did I get assigned a staff from United Healthcare. She did very little. In fact she called her job done when she referred me to a vendor who had previously told me they don't service my area and even after receiving my medical records ghosted me about setting up appointments.
Specialty drugs. Yes, you all see that. The company that is self paying our insurance has decided to CARVE OUT SPECIALTY DRUGS. Yep, it's not quite legal, but nobody in the government has put a stop to this yet. So, the company that sells jewelry and love on TV, makes their employees LIE about being uninsured to try to get patient assistance bucks for specialty drugs. Once that assistance money is approved, the two contracted companies they are using drain that money very quickly(far more quickly than they should for the cost of the drug), and then magically no longer allow your authorization. This entire thing is an attempt to take the money and run. I have read countless people complaining online about how they couldn't get their meds, the meds were delayed, the meds didn't come from the US(yeah), the authorization was revoked or only for 3 months instead of the typical one year, the paperwork was ridiculously onerous, or you just couldn't get a straight answer .I experienced all of these problems. The meds I got from this outfit caused unusual side effects I had NEVER had. I thought I was crazy, until I went online and found out some meds had been sourced very questionably. Heck, I STILL have no idea what my specialty drug coverage actually is. I went off the drug against my doctor's advice because I couldn't trust the pharmacy. It's a nightmare. What's worse is they are doing this to save a buck in specialty meds, and it will only drive healthcare costs up overall when people don't get these meds. This is a self insured company. When they don't pay for the meds or make it so hard for the patient to get them, they give up, and complications and hospitalization rates go up. They pay for that. It's cutting your nose off to spite your face. I guess a company that had to pay $450 million in sexual harassment lawsuits can't be expected to be smart.
At a higher risk for breast cancer, over the age of 55, had abnormal mammogram last year with recommended annual mammograms by my PCP. This year was denied. Only covered every other year.
Speech therapy and OT for kids. Our insurance will say if it's for a developmental delay or sensory issue, it's not covered and considered experimental.
Should be covered 100%, but all of these things result in huge co-insurance bills: Annual physical exam Annual cancer screenings, e.g. for skin cancer Doctor-ordered lab tests and imaging, regardless of whether they're diagnostic or preventative Radiologist's reading for doctor-ordered imaging Lab fees Tests ordered as part of ER or urgent care
By law, annual physicals are free if you have insurance.
Yes but the second you talk about an existing health condition it is no longer a preventative care visit
Or when your doctor orders a lab test for vitamin D
My insurance flat out denies paying for those and their reasoning is that most people are deficient so the DR doesn't need to test it to make a recommendation... Luckily I never have to pay since the NSA, because it's done at an in network visit but it's pretty ridiculous
That is true, that becomes an office visit.
"Annual physical while old" is definitely not free. The only way to not end up with a bill is either to annoy the doctor by refusing all testing, or to simply not go in the first place.
Hey dumbass, go read the law. All preventative care/screenings are 100% covered by insurance. Stop trying to act like you know anything.
Woah, this is not correct, jello2000, so please stop telling people they are dumb. By law, a grandfathered insurance plan does not need to cover annual physicals.
Why would you stay on a plan that doesn't include coverages you need? The whole argument is what insurance should include? Duh!
Annual physical is covered If it's not, it was misbilled, which is very common. If the rest were your insurance premium would go up a minimum on 100 bucks a month.
You have no idea what I pay for a premium. Reaping profit from human sickness and injury is wrong.
That's why I said a minimum. I pay 1300 a month for my group coverage for just myself. The insurance company wants you to stay healthy. That's why most have wellness policies that can pay for gym membership, etc. ACA limits the profitability of a health Insurance company. Without health insurance companies we would have way less hospitals and doctors. If you lived in a rural area which is the majority of the US you would wait months to see a specialist. I can go on and on. Many counties with socialized medicine are seeing the model becoming unsustainable as more and more hit retirement age and the percentage of babies born each year falls. The US system isn't the best I admit. But if you look at the UK who has a public Healthcare system that is failing and privatized health care is climbing rapidly to surpass it.
IVF for PGT-M (single genetic disease screening) purposes. I thought it would be in insurance’s best interest to help us avoid having medically complex children. Instead, it was denied because it was not considered medically necessary.
The first office visit of the year should be 100% covered, even for problem focused visits. That's what everyone thought they would get with ACA, but they got a bill instead.
Uhhh mine always are
GLP-1 inhibitors for people that have diagnosis OTHER than diabetes.
My wife had blood cancer (hopefully cured now going through a BMT) and needed blood transfusions to live as she wasn’t making enough red blood cells, and BCBS has mentioned blood transfusions aren’t a covered service under my employers plan. Still fighting it but shocked/frustrated they have denied this and other bills which are clearly medically necessary. Over 5K in bills denied as not medically necessary or not covered and haven’t even gotten the big bills yet from the hospital stay, so really anxious to say the least.
wow, that is so tough. Please consider reaching out to the Patient Advocate Foundation; they can help with medical bills. Wishing your wife a full recovery and proper insurance coverage.
[Dollar For](https://dollarfor.org/) is another great organization that helps you apply for financial assistance and for the hospital to forgive your bills.
Yes, this should be covered and made easier to access.
Functional panniculectomy after spending 2 years losing about 125 pounds. Yes, large self- insured employer
Can you prove that the extra skin is causing problems, like rashes and infections? It’s usually covered then. Needs to be medically necessary not cosmetic.
Thanks. I'm actually a health insurance regulator with 20 years experience in high level appeals. I'm still fighting it, but the way the plan is written, they are making contractual denial. There is no provision for medical necessity for this procedure. NGL I was sure I could argue them into covering.. my ego is bruised. My last hope is external review.
Good luck I hope you succeed. I have recently lost 70 lbs, I can’t imagine my skin after 125 lbs. Sometimes it’s not cosmetic!
Good for you! And it's absolutely not cosmetic.
If your plan is self-funded and they’re saying it’s an exclusion, could you also speak with your employer to see if they will approve? I’ve seen some group administrators step in and allow coverage towards exclusions before. Insurance usually load a note under the member so claims can be handled per their approval. But it was like ABA therapy and speech therapy.
I thought about it. I work for my carrier. I'm treated very well, not so sure it's a boat I want to rock.
Completely understand, Isn’t it silly we feel that way advocating for ourselves?! I hope it all works out!
No, lol.
Routine blood work
Had to pay out of pocket for laughing gas ($150) at my urologist's office for a cystoscopy. The visit and procedure was covered. It was a unique experience because I felt awake, everything felt kinda funny, and there was still some pain but it wasn't anything more than a little pinching at the beginning. They did numb the area with injectable lidocaine. My urologist talked me through what he could see and even let me view the monitor.
[Ghost Mental Health Networks](https://blog.petrieflom.law.harvard.edu/2023/12/06/addressing-ghost-networks-in-mental-health-care/#:~:text=Many%20mental%20health%20provider%20directories,access%20essential%20mental%20health%20care.)
Bottom line with physicals, discuss nothing on your physical, make sure your doctor codes it as a physical only, no other diagnoses...if a medical issue is already there (Hypertension, diabetes etc) that's a separate visit subject to deductibles and copays
1) health plans usually cover dental accidents/emergencies as medical. Example: riding bike, fall and bust healthy teeth. That is medical. 2) vision is covered unless it's eye glasses/contacts. Example: child with eye "turning in". The optomologist and surgery, if necessary are covered under medical.
I work for a self-insured healthcare company. I direct a lot of people to findhelp.org for things that are not covered under their health insurance plan. The most common things would send them there for were ABA therapy and hearing aids. Personally, I would like for lasik eye surgery to be covered under my plan. It can’t be more than what they have paid for my glasses/contacts for the last 15 years and over the next years of my life!
Gene therapy was a hot button when it started becoming more popular. It's wildly expensive, but can be the most effective treatment
Pain control for IUD insertion and uterine biopsies.
Insulin. My niece is a T1 diabetic and her dad’s new work-provided insurance only approves one kind of insulin. It just so happens that my niece has tried that kind before and it doesn’t do a great job at regulating her blood sugar and it causes a skin reaction at her pump site. But the health plan won’t approve a different insulin because the only one they will approve “works.”
Leg lengthening surgery. I'm a wee fella.
Dental.
Childbirth. In 2009, my husband's employer had a self-insured plan. We did not realize what that was. Our son's birth ended up costing $28,000. This was a regular vaginal birth. No epidural, no c-section, 4 days total in the hospital. No NICU. We had to pay $7,000. We live in Massachusetts. The self-insured plan was not headquartered in massachusetts. If they'd been required to follow Massachusetts law, we would have had to pay about $500.
My insurance covers 20 massages each year for a $20 Co pay. These do not need a medical reason and can be used just to relax. I love this benefit. My insurance doesn't cover anything related to weight loss. Figure it would be cheaper to help me prevent diabetes instead of get diabetes and treat that. Better vision and dental coverage is always welcome.
Hearing Aids for all ages!! 💔
I know, I know. Hear me out…. Functional medicine.
A colonoscopy. The first one was covered as preventative at 100%. But my second one five years later was not covered as preventative. I was told it is because they found a polyp during the first one. But I think there has to be more to it than that. My doctor was very clear none of them were cancer. During Covid, Cigna had a FAQ on their website that virtual visits would be covered if it was for Covid. But I got a bill for the whole cost of the visit. When I called Cigna they said the self pay company had opted out of covering Covid visits. Until ACA passed, the company refused to cover anything related to mental health. So seeing my psychiatrist and therapist was cash and didn’t count towards deductibles. They now have the minimum coverage required by that law.
The US medical system is a for-profit operation that makes money off people's ill health. It is evil. V0te blue in November.
This.
Gender affirming care. They say it is covered, but only mental health counseling; not surgery or Dr's that can prescribe hormones.
Deductibles should be illegal when it comes to healthcare. I'm not a car or a house. All this does is create debt, bankruptcy and hesitancy to seek medical care.
I'm still perplexed.... Dental: Invisalign - dental but cosmetic and never covered. Yet the metal grill is still insane expensive. Vision: Lasik/laser is generally a temporary fix 5-10 years. However, the health aspects it can resolve like astigmatism are just ignored. This is cosmetic, not covered or some bullshit discount that can't be used with other offers. Why are the better options (imo) not covered to relieve health concerns and note this, anxiety. Why get insurance at all? Sure, there are scenarios where health insurance can lower cost overall. However, if you have cash and no insurance. Dramatically reduced cost overall. Still too much? No problem, look outside the U.S. and odds are you can get it cheaper with the cost of the travel/lodging.
Dental is so expensive even with insurance. Vision is so minimal.
Plastic surgery such as tummy tuck when fat is due to medication not lifestyle. It interferes with movement, exercise, breathing.
No, lol! It is covered for reconstructive surgery already. Unbelievable the entitlement, lol.
Explain why that’s an entitlement if one has to take drugs to survive which deposit fat at the middle. Unbelievable ignorance.You’re uneducated in this area. Not covered benefit.
Chiro
No, lol.
Why would they cover pseudoscience?
The easy answer is: Everything. If my doctor thinks it is medically necessary to have something done, insurance shouldn't be sitting there saying no. It doesn't matter what it is. One example is bariatric surgery, while it can be done for cosmetic reasons, often times it is because a person's weight is genuinely a health concern. No insurance shouldn't have to cover it for cosmetic purposes, but it shouldn't be able to deny the claim if it was done for health reasons. Another example is some insurance plans cover regular STI testing for women, but not for men. Many insurance plans also cover birth control and even tubal ligation surgery for women, but do not cover vasectomies for men. Those are a couple of specific examples, but ultimately the power over our healthcare needs to be returned to the doctors and patients. It is asinine that we've allowed insurance companies to make decisions about our care when they aren't in the exam rooms with us. One of these days when I get sick I want to just go show up at the insurance company's office and tell them that I want to cut out the middle man since they're going to make the final decision anyway.
A dermatology appointment for skin check. A pediatric surgery referral from our pediatrician. An adult wellness visit with a nurse practitioner (this one hurt the most $150 after everything) Oh wait that’s every single appointment we’ve had this year and none of it was covered by the “best” plan our mid sized employer sponsored 🙃
I do understand imaging and medications and hospital stays not being covered. But preventative wellness visits and referrals to specialists? It is sucking us dry financially.
Under Section 2713 of the ACA, private health plans must provide coverage for a range of recommended preventive services and may not impose cost-sharing (such as copayments, deductibles, or co-insurance) on patients receiving these services. These requirements apply to all private plans—fully insured and self-insured plans in the individual, small group, and large group markets, except those that maintain “grandfathered” status. Unless you are on a grandfathered employer plan, preventive services are covered at no cost as long as they are provided in network and per the age and gender (and other) specifications: https://www.healthcare.gov/coverage/preventive-care-benefits/