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  • Every health insurance plan is different
  • All medical treatments and services may or may not be covered under your policy
  • Pre-existing conditions can determine eligibility


Having quality health insurance is no longer optional. It protects you in the event of a serious illness or accident.

Also, having health insurance improves overall health as participants have access to routine health screenings and doctor visits when necessary. However, most health insurance does not pay for everything.

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What isn’t covered under my health insurance plan?


Many health insurance policies have premiums, deductibles and co-payments that health insurance companies expect participants to pay. Other areas not covered by a health insurance provider could be:

  • Pre-existing conditions
  • Annual limits
  • Non-covered prescriptions or procedures
  • Out-of-network providers

Most health insurers will also not pay for procedures the company deems to be outside of the definition of “usual, customary and reasonable.”

What are premiums, deductibles and co-payments?

Health insurance companies quote yearly premiums for health insurance coverage typically based on policies where the policyholder has to pay a portion of the medical bill known as the deductible.

A deductible is another cost associated with many health insurance policies (outside of your premium) and must be paid out-of-pocket by you before the coverage will begin to cover the costs of prescriptions or medical services.

A deductible can be met through the payments for:

  • Doctor visits
  • Hospital stays
  • Some medical equipment
  • Prescriptions
  • Cost of some over-the-counter medicines

A third cost that is commonly paid by participants in a health insurance plan is co-payments. Co-payments are a set amount (generally under $100) that must be paid out-of-pocket for doctor visits, hospital stays or prescriptions.

For instance, a visit to a doctor’s office might cost the participant $25 every time. The co-payment covers some of the cost for the visit, and the insurance company pays the rest.

Generally, a healthcare provider will not render services until the co-payment has been paid.

Premiums, deductibles, and co-payments will vary from insurance plan to insurance plan with each insurance provider using various percentages and other criteria to set each amount. Some of the amounts can vary within a certain plan as well.

For example, a health insurance provider might have a $10 co-payment for generic drugs and a $25 co-payment for name brand drugs.

What is a pre-existing condition?


A pre-existing condition is any health condition that existed before the health insurance coverage. Many health insurance providers will not cover services associated with pre-existing conditions, as there are usually high health costs associated with them.

  • Each state has its own laws and rules governing how long a health insurance plan can exclude payment for services for a pre-existing condition; the longest amount of time is 12 months.
  • Recent legislation has changed some of the rules regarding insurance companies’ abilities to exclude or deny coverage for pre-existing conditions.
  • Health insurance companies can no longer exclude or deny coverage for children under the age of 19 due to a pre-existing condition.

There has been quite a large backlash against the insurance industry, as millions of Americans cannot get health insurance due to pre-existing conditions.

What are annual limits?

Health insurance companies sometimes set an annual, limit on how much they will pay for medical services to each participant or family group. Once that annual limit has been met, the insurance company will not pay for any more medical services.

This annual limit serves to protect the health insurance company if a participant becomes seriously ill or has an accident that requires very high medical bills.

Health insurance companies used to be able to set a lifetime limit on an insurance plan. Thankfully, recent legislation has banned lifetime limits and restricted the use of yearly limits.

Why would a health insurance provider not pay for a prescription, service, or particular doctor?


Some health insurance plans have preferred prescriptions and doctors that they want participants to use. It could be that the insurer has an agreement with a particular doctor or medical group to perform services at a lower cost.

The providers who take part in the agreement are generally called a “network.” Sometimes insurance companies will not pay for services from doctors or hospitals that are outside of the network.

Consequently, many health insurance companies will not pay for specialists that have not been referred by an “in-network” doctor.

Similarly, if a prescription is not on the preferred prescription list, its cost might not be covered by the insurance plan. Medications that are new or deemed, as not medically necessary, such as erectile dysfunction drugs, might not be covered.

In addition, the insurance companies might not pay for medical services that are deemed not medically necessary. Services such as fertility treatments might not be covered because it is not deemed medically necessary.

What does usual, customary, and reasonable mean?

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Health insurance providers use the terms usual, customary and reasonable to protect the company from fraudulent health claims and claims for non-essential services.

Health insurance companies have average amounts they will pay for a particular medical service.

An insurance provider can deny claims that are deemed unusual, alternative or unreasonable. This protects the insurer against claims that are fraudulent.

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[su_spoiler title=”References:” icon=”caret-square” style=”fancy” open=”yes”]

  1. https://www.healthcare.gov/community-health-centers/
  2. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Downloads/Prescriber_Methods.pdf
  3. https://www.healthcare.gov/coverage/pre-existing-conditions/
  4. https://www.drugs.com/answers/difference-between-preferred-non-preferred-drugs-621041.html