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Legal Issues and Health Insurance

Don't Always Count on Coverage
Walt Ayres, J.D.
  Question:
What features are usually not included in a typical health-insurance policy?
Answer:
While health-insurance coverage varies widely among health plans, as well as among different U.S. states, some items such as long term-care coverage are typically excluded. Other items such as birth control and infertility treatments have been controversial.
Consumer demand can ultimately change the availability of coverage. Legislation reflects consumer demand, as in the case of the recently mandated coverage for 48-hour minimum hospital stays after childbirth. Sometimes a judgment call by your physician or insurer is required to determine whether a treatment is "medically necessary" and therefore covered under your health-insurance plan.
It's important to learn the specifics of your plan before jumping to the conclusion that the care you need is not covered. Your plan may indeed include some of the features listed below that are usually excluded from health-insurance policies. And you can always ask your doctor whom to call if you're concerned about being unable to get the care you need.
Plan Variation
According to a study conducted by the Agency for Health Care Policy and Research (AHCPR) of the Department of Health and Human Services, health plans vary widely in their coverage. Nonprofit HMOs are more likely to avoid new technologies, including laser medical technologies and other cutting-edge treatments, unless they produce cost reductions. In other words, depending on your insurer, you may be denied coverage for medical care that requires the use of new technologies.
Cost cutting by some HMOs has eliminated or reduced coverage of some popular drug therapies. Medications like Prozac for depression, Lipitor for cholesterol reduction and Prilosec for ulcers may not be compatible with an HMO's budgetary goals. Some plans require patients to pay for such drugs themselves or to pay higher copayments than they would for a substitute drug favored by the insurer.
Birth Control and Infertility
Insurance for birth control pills and infertility is not a sure thing. For example, millions of California women cannot purchase birth control pills under their insurance plans. However, two California state senators have recently introduced legislation that would require some coverage for birth control, prompting religious leaders to seek exemptions for HMOs with religious affiliations.
Religious objections also play a role in the controversy over coverage for infertility. The Catholic Church regards some treatments for infertility as similar to abortion because human embryos may be destroyed during fertilization procedures.
Infertility coverage is not yet typically included in health-insurance contracts. Several states mandate infertility coverage to some extent, but many insurers still do not provide coverage for infertility.
Alternative Treatments
In years past, alternative treatments such as chiropractic and acupuncture have not been strong candidates for coverage under typical health plans. However, a recent study conducted by National Market Measures, Inc. for Landmark Healthcare indicates a trend toward increased coverage for alternative therapies. According to the study, 67 percent of HMOs already insure at least one type of alternative treatment. Chiropractic is most commonly covered, followed by acupuncture and massage therapies.
Health plans based in the Western part of the United States are more likely to cover alternative medicine. According to the Los Angeles County Medical Association, more health-plan members expect and ask for treatment alternatives in this part of the country.
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