Health insurance is a great way to ensure that you have access to the medical care you need. However, it's important to be aware that not all services are included in health insurance policies. Generally, health insurance covers most doctor and hospital visits, prescription drugs, wellness care, and medical devices. But elective or cosmetic procedures, beauty treatments, the use of unauthorized medications, or entirely new technologies are usually not included.
Before the Affordable Care Act (ACA) was passed, health insurance providers had the freedom to decide which services to cover and which not. The ACA created a standardized group of 10 essential benefits that should cover all individual and small group plans (available to companies with less than 50 employees). These ten essential benefits cover many health care needs, such as doctor visits and hospitalization, but health plans are not required to cover other services. If you don't have long-term care insurance or qualify for Medicaid coverage (most nursing home residents do qualify for Medicaid, which pays for custodial care once the person has exhausted most of their assets), you'll have to pay for medical care in your nursing home, assisted living facility, or custodial home yourself.
Additionally, if your health insurance policy has an unlawful act exclusion, it means that you won't be covered for health care expenses caused by your participation in an illegal act. Every year there is an open enrollment period where people can compare health insurance policies and choose or change health plans. Health insurers have lists of covered drugs called formulae, and insurers have a lot of flexibility when it comes to creating their forms. Routine medical care that includes tests, checkups, and patient counseling to prevent diseases, illnesses, or other health problems is typically covered.
However, if the purpose of staying in a nursing home is solely custodial care (that is, assistance with activities of daily living, rather than struggling to regain lost skills and return to your own home), then your stay in the nursing home is not covered by health insurance. While all health insurance plans with no acquired rights cover the vaccines that are commonly recommended for preventive care in the U. S., if your insurance company or Medicare determines that you should have been under observation when you were admitted as an inpatient, the insurance company may refuse to pay the hospital bill.
