Understanding How Special Procedures Are Covered

A typical health plan covers many important healthcare services, but you would be hard pressed to find a plan that offers coverage for every kind of service or procedure. Whether you have coverage for certain special procedures could depend on things like the policy you have, your benefits, or any additional coverage you might be enrolled in.

That’s why it’s important to read and understand the details of your health plan before having a procedure, including what’s covered and what’s not. You may discover that separate, additional coverage is needed for services like the ones below that are not covered by most typical health plans.

Dental Care

Other than the pediatric dental benefits required by the Affordable Care Act, most standard health plans don’t include coverage for dental services. You can check with your employer to see if they offer a separate dental plan you can enroll in, or you can purchase one on your own.

Most dental plans will cover the full cost of preventive care like routine office visits. Depending on your policy, it may also cover part of the cost for other procedures after you meet your deductible. Those services may include: 

• Fillings
• Crowns 
• Root canals 
• Oral surgery 
• Periodontics
• Orthodontics
• Bridges and dentures

Keep in mind, certain dental plans may have coverage limitations or a maximum annual benefit that limits how much your plan will pay for each dental service each year.

Vision

Like most dental services, a lot of eyecare services are not covered under standard health plans. You will need a separate vision plan if you want coverage for things like routine eye exams, corrective glasses or contact lenses, and frames. Vision correction surgery is also less likely to be covered even by many vision plans. 

Some plan providers may offer discount programs. While these programs aren’t really considered vision insurance, they can make certain services or products more affordable for those enrolled. Discount programs usually require you to get services from an eye doctor in that program’s network, but you would need to check your specific program’s details.

Weight Loss Procedures

More than 40% of adults in the U.S. are obese, which means they have a body mass index (BMI) greater than 30.1 For most people, doctors will encourage healthy, nonsurgical techniques to try and reduce their weight first. But for those who are unsuccessful with nonsurgical methods, weight loss surgery may be an option, especially if your doctor believes it’s necessary for your health. 

A standard health plan might cover certain weight loss procedures; but you would need to meet certain requirements, such as:

• Having a BMI of 40 or greater
• Having a BMI of 35 or greater, plus at least one obesity-related medical condition, such as:
  • Arthritis
  • Sleep apnea
  • Type 2 diabetes
  • High blood pressure
• Nutritional or psychological evaluations

Fertility Services

Currently, only 17 states have laws requiring health plan coverage for infertility treatment.2 If you live in a state that doesn’t require coverage, you may still have benefits available for diagnosis and treatment through your health plan carrier or employer. Be sure to check with them for details.

Know Your Coverage And Plan Ahead

Understanding the benefits you have available through your standard health plan or any additional coverage, and how that affects any out-of-pocket costs, will help you be as prepared as possible before you receive care. If you’re unsure how your health plan covers special procedures or services, ask. Your plan provider or benefits administrator will know what your plan covers. Also, remember that going to care providers in your plan’s network for any type of care can help you avoid unexpected and potentially costly medical bills.

Learn More About Your Special Procedures Coverage

If you have an Anthem health plan, you can visit anthem.com to review your benefits and how your plan covers special procedures. 

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