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Understanding Health Insurance Coverage: A Primer
by: Peter Lenkefi
Health Insurance Coverage: What are ‘Covered’ Services?
Health insurance coverage is a contract used to determine medical benefits that are covered, or not covered, between you and your insurance provider. The insurance company, based on a fee that you provide them on a regular basis, promises to pay health insurance coverage on certain items or benefits listed in that contract. These are called ‘covered’ services. ‘Covered’ services can include a wide variety of things, such as implements, prescriptions, services (such as massage), checkups, tests and/or research.

Your contract should also list all of the things NOT covered in your health insurance coverage – these are items or services that you will need to pay for out of your own pocket, should you require them.

Health Insurance Coverage: What is a Medical Necessity? How is this Different from Covered Services?
Just as it seems, a medical necessity is something that your health professional has deemed a required service/ item that will affect your health negatively should you decide not to purchase it. However, just because your doctor tells you something is a medical necessity does not mean your health insurance actually offers coverage for it.

Since insurance companies decide what health coverage they will and will not provide, you really have no leeway in this area.

Health Insurance Coverage: What Do I Do?
Most doctors try and keep themselves abreast as to what the major insurance companies do, and do not cover when it comes to health coverage. However, there are a LOT of plans out there, so this just isn’t enough. So how can you avoid any nasty surprises during an emergency?

Read your health insurance coverage. You’re better off knowing what your health insurance company will, and will not provide coverage for right off the bat. Then, if your doctor decides on a treatment plan that isn’t covered, you can ask for alternatives that may be.
If there are questions regarding your health insurance coverage, do not hesitate to contact the insurance company. Questions are good, and they expect them.

Health Insurance Coverage: What Do I Do if Something I Need Isn’t Covered?
The gross majority of what your doctor orders for you will be covered in your health insurance plan. If you do get a treatment or supply that isn’t covered, you can always challenge the health insurance coverage. You may not be the only one who requires the same type of service, benefit or item – so you’ll end up fighting not just for yourself, but for others in the same situation.

Ask your doctor for their side, and use this in your claim. It may not help in the end, but if your doctor is on your side, you may be able to convince the health insurance company that coverage is required.

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