1. Breaking the Law. Your health insurance might not pay for healthcare costs you racked up doing something illegal. Known as an illegal-act exclusion, if your health insurance policy has one, it means you won’t be covered for healthcare costs caused by your participation in an illegal act.
Rack up an emergency room bill for $2000 when you burned yourself lighting the grill at the family picnic? It’s probably covered. Rack up a $200,000 charge from the critical care burn-specialty unit after you caught your hair on fire while freebasing cocaine? If your health insurance policy has an illegal-act exclusion, that bill will be coming to you.
2. Travel Vaccinations. Getting shots before your exotic foreign vacation? Your health insurance might not pay for your travel vaccinations. While health insurance is likely to cover vaccines routinely recommended for preventative care, vaccines for tropical diseases that aren’t a problem where you live are probably not covered by health insurance.
Need a tetanus shot because you cut your hand gardening in your back yard? The bill is probably covered by your health insurance. Need a yellow fever vaccine so you can go rafting down the Amazon River? Be prepared to pay for it yourself.
3. Prior Authorizations Do Not Guarantee Payment by Health Insurance. Do you think getting prior authorization from your health insurance company for an expensive MRI, CT scan, or procedure, means the insurance company has agreed to foot the bill? Think again.
Many health insurance companies require pre-authorization before an expensive test or procedure is done. But, just because your insurance company pre-authorized a test doesn’t mean your insurance company will actually pay for it.
Prior authorizations generally include a clause that goes something like this: “This authorization is not a guarantee of payment. Benefit coverage is subject to medical necessity and member eligibility.” This means if the insurance company decides after-the-fact that the expensive test or procedure wasn’t necessary, it can refuse to pay the bill even though it pre-authorized the test or procedure.
4. Incorrect Hospital Admission Status: Observation Status vs. Inpatient Status. Your health insurance might not pay for your hospital stay if you were admitted as an inpatient but your insurance company thinks you should have been in observation status.
When you’re put into the hospital, you’re assigned a status. The two most common are inpatient status and observation status. Observation patients are technically outpatients, although they stay overnight or even longer in a hospital room just like inpatients. You have no way of knowing which status you’ve been assigned unless you ask.
Your admission status is very important to your wallet. If your insurance company or Medicare determines that you should have been in observation status when you were actually admitted to inpatient status, the insurance company can refuse to pay the hospital bill.
Sort of a technical foul, observation versus inpatient errors allow health insurance companies and Medicare to refuse to pay the bill. They’ll claim the hospital stay is not covered by health insurance since the hospital broke the rules by admitting you to the wrong status.
On the flip side, if you're placed in observation status, since you’re technically an outpatient, you might be responsible for a larger share of the bill than you would have been as in inpatient. Outpatient services usually involve coinsurance and might not bundle services together. So, you could find yourself paying 20% coinsurance on each and every blood test, x-ray, injection, Band-Aid, and treatment you received while you were in the hospital as an observation patient.
While the bill for your share of cost for outpatient services might seem outrageously large, think twice before you argue for inpatient status. A health insurer can deny the entire inpatient hospital bill if it determines the care should have been provided in outpatient observation status instead of as an inpatient. Learn more about observation status, how observation guidelines work, and why it costs more.
5. Nursing Home Care. Think your health insurance or Medicare will pay for nursing home care when you’re unable to care for yourself? Think again.
Neither Medicare nor private health insurance companies pay for long term care. You’ll have to pay for your nursing home, assisted living facility, or home health care yourself if you don’t have long term care insurance.
This doesn’t mean that Medicare and health insurance companies won’t ever pay for a nursing home stay. In fact, Medicare might pay for short term, skilled rehabilitative services in a nursing home. But, it won’t pay for long-term custodial services.
The key here is why you need the nursing home. If the goal of the nursing home care is rehabilitation, in other words, if you’re trying to regain skills you have a reasonable chance of regaining, then your health insurance company might pay for a nursing home for a short period of time. For example, you might be allowed a nursing home stay after a debilitating stroke while getting intensive physical, occupational, and speech therapy to help you re-learn how to stand up from a seated position, feed yourself, and brush your teeth.
If the goal of the nursing home stay is purely custodial care, then your nursing home stay is not covered by health insurance.
There are two notable exceptions. Medicaid, the state-based government insurance program for low-income people, sometimes covers long-term nursing home care. Also, many hospice programs provide an option for nursing home or inpatient hospice-center care. But, since hospice services are for terminally ill people with a life expectancy of less than six months, you’re not likely to need this benefit for very long if you qualify for it. (с)
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