Understanding health insurance limitations and rules

insurance news coverage

Health insurance continues to be a problematic and confusing issue for many people.

health insurance coverageWhile some may be taking steps to understand their insurance policies to the best of their capabilities, they could still be exposed to problems that are difficult to recognize. Visiting a doctor, for instance, is something that many people do not give a second thought to because they often believe that their insurance policies will cover instance of medical care. This is, however, not the case.

The simple act of visiting a doctor can turn into an expensive problem for those that have a limited understanding of insurance coverage in general. There are rules that determine who you can see and whether or not a type of medical test will be covered by your insurance policy. There are some important questions to consider before you go to a doctor to make sure you avoid falling prey to the expensive consequences of breaking these rules.

Is my doctor in my health plan’s network?

This is an important, but often overlooked question. Many medical practices participate in several types of health care plans, but no single plan includes all medical practices. Insurers often offer a glimpse of the practices that are included in their networks on their websites, but these lists may not be up-to-date. One of the best ways to determine whether a medical professional is included in an insurer’s network is to contact that doctor’s billing office.

What are the limits and exclusions of my health plan?

Insurance plans must provide coverage for essential health benefits, such as visits to physicians, acquisition of certain medications, maternity care, and mental health care. The specifics of what is actually covered by insurance plans can be difficult to understand, however. Many plans have limits on what they provide coverage for. For instance, insurance plans often have a payment ceiling concerning physical therapy.  Examining a plan’s “summary of benefits and coverage” section can be a good way to figure out what these limitations are.

How is medication covered?

Medication can be a tricky subject when it comes to insurance coverage. Every health plan often has its own list of preferred medications that it provides coverage for. These lists are often organized into four tiers, with the first tier focused on generic medication. Higher tiers tend to cover more expensive medications, but are also coupled with higher co-pays. When faced with figuring out whether a medication is covered under a health plan, finding out what tier this medications falls under will help you figure out how much you will be paying for it. If the medication is too expensive, you can often speak with a doctor or pharmacist to find a similar medication that falls under a less expensive tier.

There are certain terminologies that are also the subject of confusion for many people. Understanding payment terminology can help you determine the actual value of your insurance plan.

Out-of-pocket limits

This identifies the maximum amount of money you will be spending on medical care. Currently, the maximum out-of-pocket limit for individuals for 2014 is set at $6,350 and $12,700 for households.


Deductibles are one of the most misunderstood aspects of health insurance policies. Many people confuse deductibles with premiums, but a deductible is the amount of money you must pay for covered services before you insurance coverage actually begins covering the costs of medical care. Deductibles tend to have a set rate for an insured year. Once the deductible is met, insurers are responsible for all costs associated with covered medical care.


Coinsurance refers to cost of covered services that you are financially responsible for. Your coinsurance percentage determines how much money you will pay for medical care, even if you have met your deductible.

Understanding the rules and limitations of your health plan is important in avoiding any undue costs you may face in your medical care. Insurance can be a difficult subject to understand, and getting all the information you need can be time consuming. Being informed, however, can potentially save you a lot of money.

Leave a Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.