Health insurance always comes with limitations on what the policy will cover. If you had a problem with your health when you bought your policy, you may have gaps in coverage you can eliminate this October. These limitations will be defined in a document attached to your policy, known as a rider, waiver, or exclusion.
How Do Riders Change Your Coverage?
It depends on the health problem. If it’s chronic, you could have a plan that won’t cover treatment for something like asthma, for example. This might be considered a “permanent” exclusion. You could also have a temporary limitation on coverage.
For instance, if your medical records showed treatment for a back injury that was likely to heal, an insurance company would probably accept your application because they didn’t expect your claims to be high after your back healed. That company might add a rider that limits your coverage for treatment related to your back injury for a year and then lift it and pay for related claims after the first year.
How to Understand Standard Exclusions on Coverage
Check the benefits section of your policy. The way a company defines certain words may limit your coverage. For example, a policy might define an emergency as “a life threatening condition that cannot be reasonably treated by your primary care physician.” While you may think going to an emergency room to see if you broke your arm would be covered, the insurer might require you see your regular doctor.
Review how your policy defines things like:
- Medical emergency
- Medically necessary
- Accidental injury
- Experimental or investigational
- Pre-existing condition
- Reasonable and customary
Another important section to look at is what procedures you must follow for medical care to be covered. You may need to talk to your insurer for clarification. For instance, a company might say your primary care doctor is responsible for arranging for your services, making referrals and approving treatments. Does that mean emergency treatment requires approval through your primary care doctor? Talk to your insurance company for clarification.
How to Get Waivers Removed in 2014
If you have some exclusion on your current health plan, talk to us starting in October about a plan that will not have exclusions. Starting on October 1 for policies effective January 1, insurance companies cannot refuse to cover you based on health problems, nor can they charge you any more than someone else in the same rating area, age, and smoking status. However, these plans may be more expensive than your current plan, so you may want to keep your existing policy if the exclusion on it is minor. Note that only people who have “grandfathered” plans that were in effect prior to October 23, 2010, will be allowed to keep their current policy. Everyone else will be converted to one of the new “Obamacare-approved” plans.
If you are not certain what to do, talk to us about your situation. We’ll compare plans from different companies and help you decide o
I have been in the health insurance business for over 12 years. I’m passionate about Health Savings Accounts and enjoy blogging about them. I am also a husband and father of 2 beautiful children.