Health insurance polices vary dramatically with regard to their limitations and exclusions, so make sure you’ve carefully reviewed this information before choosing a group health insurance plan. Common limits and exclusions include:
- Pre-existing conditions: Most group health insurance plans have waiting periods for pre-existing conditions if the employee had a lapse in coverage for more than 63 days. These waiting periods can range from six months to a year. For example, if an employee has asthma, leaves a previous job, and does not carry health insurance for 63 days or longer, any asthma-related expenses would not be covered under the new policy until the waiting period had expired.
- Cosmetic surgery is rarely covered by group health insurance, except in cases of reconstructive surgery following an injury or to correct a birth defect. If a doctor states there is a medical need, such as to repair a cleft palate, cosmetic surgery may be covered. Breast reduction surgery may also be covered if there is a medical need, such as back injury. However, cosmetic procedures such as liposuction or breast augmentation are not covered.
- Alternative medicine treatments are often not covered by group health insurance plans. Alternative treatment is defined as a treatment used in place of conventional medicine; complementary medicine is treatment or procedures designed to be used with conventional medicine. These treatments include acupuncture, acupressure, massage, yoga, and biofeedback. Some health insurance plans also define treatments as alternative medicine that is not covered. Typically, the health insurance company determines what is considered experimental, non-traditional, alternative in nature, and denies coverage for those services.
- Home care and private nursing care expenses are the most common health care expenses that are not covered under a group health insurance plan.
- Mental health treatment varies by plan. Some plans cover mental health costs and drug or alcohol rehabilitation. However, some may only cover substance abuse costs if it occurs in conjunction with mental illness. A referral from the primary care physician may be required to gain access to these services. You can also offer an Employee Assistance Program (EAP) to offer mental health and substance abuse coverage to your employees.
- Drug benefits may exclude cosmetic treatments such as supplements for hair growth or acne. Non-traditional drugs such as food supplements are usually excluded, as are drugs that the insurance company views as experimental.
Limits and exclusions can dramatically affect the overall health care plan you are offering employees, so make sure you understand all the provisions of the plan you select.