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What limitations and exclusions might apply to health insurance?

Dr. Michael Roizen, MD
Internal Medicine

Your health insurance may have some exclusions and limitations. Plans vary so much that it’s hard to say exactly what limits and exclusions might be in yours. To make sure you know the ins and outs of your policy, you need to read that entire insufferably boring booklet (summary plan description (SPD)) with all the policy rules and limits and bylaws and heretofores and therewiths. You can get it from your HR department or the insurer. If it makes it more enjoyable, read it aloud and set it to song.

In general, though, health insurance plans can limit coverage for a pre-existing condition only for a certain period of time, usually no more than 12 months. Many plans have a three-month waiting period before all benefits kick in. However, it’s important to note that under the Affordable Care Act of 2010, health insurers can no longer place dollar limits on health care they cover in your lifetime.
Pre-existing conditions: Most health plans will have 6-to 12-month waiting periods for pre-existing conditions if there's been a lapse in insurance coverage longer than 63 days.
Cosmetic surgery: Health insurance rarely covers cosmetic surgeries. Typically they must be for reconstruction after an injury or due to a birth defect, or if a doctor determines a medical need for it. Additionally, drugs used only for cosmetic purposes-like hair growth stimulants or skin or nail supplements-usually aren't covered.
Non-traditional treatments: Health insurance often does not cover treatments that are used in place of or in concert with conventional medicine. These alternative or complementary treatments include acupuncture, yoga, acupressure, massage and biofeedback. Some plans place chiropractic care in that category and will not cover it. Non-traditional drugs, such as food supplements, and any drug considered experimental are typically not covered either.
Home care and private nursing care: Home care and private nursing expenses are among the most common expenses that insurers don't cover. The Centers for Disease Control and Prevention say more than 1.4 million patients use home health care, with the average patient requiring at least 60 days of treatment.
Mental health treatment: Some plans cover mental health treatment and, conditionally, drug rehabilitation. Accessing these types of services might require a referral from a primary care doctor. Many employers offer mental health and substance abuse services through an employee assistance program.
Abortion services: Elective abortions and drugs used to abort a pregnancy aren't covered.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.