The More You Know - Health Coverage

My career is in the health care/insurance world and I often either get questions from people about how things work or see comments from people who don't understand some concepts, which are understandably confusing! So, here's my little mini-training:

Q. Why doesn't my health insurance cover (insert care/item here)?

A. There are quite a few reasons. The first may be that in all the large-scale studies that have been done, that care/item hasn't been shown to be more effective than another option, and it costs more money. It may seem more effective to you, but insurer has to think about everyone they cover and can't make broad decisions based on individuals - they have to think in terms of serving the greatest number in the most quality and cost-effective ways that it can. And when they make a decision for one person, that could set a precedent that they have to follow for everyone who comes next, increasing everyone's costs.

Second, the health insurance company may cover it in some plans, just not yours. When your employer chose your health plan from the insurer they had many different options. Some plans covered a lot of things and cost more, some had less coverage but a lower price. Your employer decided, based on cost and the needs of the demographics of the staff and a lot of other factors, which plan to go with. That's why people who have the same insurance company can have different co-pays and different things covered. It may not have been your insurance company's decision to cover something or charge a certain amount - it was just one of the options offered and your employer made the ultimate decision. Health insurance companies don't say this because they want to maintain a good relationship with the employer and keep their business.

Think of it like this:

Your mom (employer) buys a box of chocolates (health plan) from the candy store (health insurance company). She had a lot of boxes to choose one, but she went with the one that she thought everyone in the family could share and that she could afford. You want a chocolate with caramel (gastric bypass). Unfortunately, the box she chose doesn't have caramel so you're out of luck. The candy store has caramel, but that wasn't what she bought!

But, the next time she buys chocolates, she remembers how important it was to the family to have caramel and it turns out that she has enough money this time! Now you ask for the caramel-filled chocolate and you find out that in order to get it you have to clean your room (meet established clinical criteria). If you don't meet the requirements, you can't have the caramel, even though it's right there in the box.

So, if the caramel chocolate is in the box and someone is telling you that you haven't cleaned your room yet, find out what the definition of "clean" is. Actually, that's good advice even without the metaphor.