8 Things Your Health Insurance Doesn’t Cover

Not sure what's covered? Check out these eight items that don't make the cut.


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(This article appeared previously on Grandparents.com.)

Whether you're looking to choose a new health insurance policy, going on Medicare or are unsure of the details of your current health plan, there are several services that you may think are covered but are actually not. Knowing in advance what you're going to have to pay for can help you make smart health choices.

1. Travel Vaccines

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Travel vaccines are different from general health vaccines. If you need a tetanus shot or a flu vaccine as part of your health maintenance, your insurance will generally cover them since they're considered necessary preventative care. But if you're going abroad, and need, say a Typhoid or Yellow Fever vaccine, most, if not all, insurance plans — including Medicare — do not cover these kinds of vaccines.

Insurance covers things deemed medically necessary and "somebody somewhere decided that travel vaccines are not medically necessary," says Lori-Ann Rickard, a health care lawyer and creator of MyHealthSpin.com. "I suppose the thinking goes that you don't really have to take the trip."

2. Acupuncture and Other Alternative Therapies

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Sometimes alternative therapies are covered, but it depends on your plan and your state.

"In the under-65 market, individual health insurance is not specifically required to cover massage therapy, acupuncture or chiropractic care," says health insurance expert Louise Norris, a contributor toHealthinsurance.org and Medicareresources.org. "But depending on how a state defines its essential health benefits package, these services may be covered."

For instance, chiropractic care can fall under the essential health benefits category of rehabilitative care, or ambulatory care, Norris notes, meaning a person who gets a back injury in an accident and is receiving treatment for the accident from a chiropractor would probably have coverage. But a person who visits the chiropractor every two weeks because it makes her feel better or to prevent back problems, would probably not have coverage. Also know that in most states that do cover chiropractic care, there are limits on the number of covered visits (usually between 10 and 30 visits per year).

Original Medicare does not cover acupuncture, but it does cover medically necessary chiropractic care. Medicare Advantage plans, which are an alternative to Original Medicare, can cover acupuncture and more extensive chiropractic care, but it varies from plan to plan.

3. Cosmetic Surgery

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Again, this all depends what's considered "medically necessary." If you're looking to get a nose job or a face lift because you think you'll look better, those would not be covered by insurance. If, however, you need reconstructive breast surgery following a mastectomy, that would be deemed medically necessary and would be covered.

4. Nursing Home Care

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"Regular nursing home care isn't covered by commercial health insurance plans or Medicare, although it is covered by Medicaid," says Norris. If you want coverage for nursing home care, "that's what long-term care insurance covers."

What is covered is short-term care in a skilled nursing facility. So if you fall and break a hip and have surgery, you may need assistance in a rehabilitative facility or skilled nursing facility to help with your recovery. Those costs would generally be covered since they're short-term and are the result of a medical incident. However, says Norris, "Commercial plans can place limits on the length of time they'll cover in a skilled nursing facility."

For Medicare to cover skilled nursing, the requirement is that the person must have had at least a three-day inpatient hospital stay (not counting any days that are considered observational as opposed to inpatient) preceding the stay in the skilled nursing facility. And the stay in the skilled nursing facility must be intended to help the patient recover from an illness or injury, rather than be a chronic situation.

5. Dental, Vision and Hearing

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Most health insurance plans do not include dental, vision or hearing. If you want coverage, you'll have to buy a separate plan that includes one, or sometimes all, of these services. But before you buy a plan, know that they are not regulated by the Affordable Care Act, which means they have no specific requirements in terms of what must be covered.

They also typically don't have any limits on out-of-pocket costs. "Honestly, if you look at the cost of getting a dental cleaning which is $110 twice a year where I live, the cost of paying a monthly fee for dental insurance is so much more than that, so the insurance isn't worth it," says Rickard. If you are eligible for Medicare, Original Medicare does not cover dental, vision or hearing, but there are some Medicare Advantage plans that do.

6. Weight Loss Surgery

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Medicare and most Medicaid programs cover bariatric surgery, but there's no federal requirement that private plans cover it. However, 23 states currently require some sort of coverage for bariatric surgery as part of their essential health benefits package.

That could mean some weight loss procedures are covered while others are not. And there's no guarantee that the coverage pays for all costs associated with the surgery. If bariatric surgery is something you're interested in, it's best to compare plans and look into the fine print of exactly what's covered.

7. Preventative Tests

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This one is a little murky since many tests are covered by insurance, while others are not. Mammograms, cholesterol screenings and colonoscopies are covered, for example, while Prostate Specific Antigen (PSA) screenings are not.

There are three government agencies that determine what's considered "recommended preventative care," says Norris. "If there isn't enough evidence to recommend specific preventive care, it's not included in the list of care that's covered in full by health insurance companies."

"That's why PSA tests aren't included in the list of covered preventive care, for example. Another example of a preventive screening that's not required to be covered is Vitamin D testing, since the U.S. Preventative Services Task Force (one of the three agencies that set the guidelines) considers the evidence of its value to be insufficient at this point," says Norris.

To see a list of preventative services covered for all adults, click here. To see a list of preventative services covered for women, click here.

8. Some Medications

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The good news is that prescription medication falls under the list of ten essental health benefits, which means medication is covered by insurance. However, as Rickard says, "the devil is in the details."

Health insurers have lists of covered medications called formularies, and the insurers have a lot of flexibility in creating their formularies. According to Norris, "they have to cover at least the greater of: One drug in every United States Pharmacopeia (USP) category and class, or the same number of drugs in each USP category and class as the state’s essential health benefits benchmark plan."

In other words, insurance companies do not have to cover all drugs. They can instead, pick and choose, and cover one drug in each class. It's also more likely that generic drugs will be covered more often than brand name. The best thing to do is to make a list of all medications you take, then research which medications different plans cover. Also keep in mind that formularies each have tiers of drugs. The higher the tier, the higher the out-of-pocket cost.

If you have Original Medicare, you must purchase a Prescription Drug (Part D) plan to cover your medication expenses. Some Medicare Advantage plans include prescripion drug coverage.


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