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How to Get Health Coverage for Special Procedures

January 19, 2018

The typical health plan covers a long list of important health care services, but no plan covers everything. Whether your plan covers a special procedure you need depends on the policy you have, your plan's benefits, and any additional coverage you might have.

Make sure you read and understand your policy. Know what's covered and what's not before you choose to follow through with any procedure. Consider separate coverage for those services that are outside most typical health plans.

Smile With Dental Care Benefits

Other than the pediatric dental benefits in Affordable Care Act plans, most standard health plans don't include dental services. These can be covered by a separate plan for individuals and families. This may be a benefit through your employer or one that you purchase on your own.

A dental plan may cover routine office visits, fillings, crowns, root canals, oral surgery, periodontics, orthodontics, or bridges and dentures. It all depends on your policy.

Most plans cover the entire cost of preventive care, plus a portion of the cost after you meet your deductible for other procedures. Dental plans may have a maximum annual benefit that limits how much your insurer will pay each year.

Be Clear About Vision Coverage

A vision plan typically covers routine eye exams, corrective glasses, frames and possibly contact lenses, depending on your coverage. Vision correction surgery is less likely to be covered. Some insurance companies offer discount programs that aren't really vision insurance, but can make this arrangement more affordable for members. Discount programs usually require work to be done by a care provider in that program.

Lose to Win With Weight-loss Surgery

More than a third of adults are considered to be obese, and if you're one of these individuals, perhaps traditional ways of losing weight haven't worked. A standard health plan might cover some types of weight loss surgery if your doctor believes this procedure is medically necessary for your health.

You need to meet certain requirements first. This includes having a body mass index (BMI) of 40 or greater, or a BMI of 35 or greater plus at least one obesity-related medical condition such as arthritis, sleep apnea, type 2 diabetes, or high blood pressure.

Doctors also encourage you to first try recommended non-surgical techniques to reduce your weight. You may undergo nutritional or psychological evaluations.

Ask About Fertility Coverage

Currently only 15 states have laws requiring health coverage for infertility treatment. If you live in a state that doesn't mandate coverage, all is not lost. You may still have some benefits for diagnosis and treatment. Ask your health plan carrier or your employer for the details.

Be Sure Before You Decide

If a procedure or service is "special," that means its costs may be special, too. When in doubt, ask. Your insurer or benefits administrator knows if your plan covers a procedure. Remember to stay in-network to avoid unexpected and potentially costly medical bills.