Insurance Coverage for Preventive Care, Medical Equipment & Emotional Illnesses

Part 1: The Basic Tools, Chapter 2: Understanding the Language of Health Insurance Page 16

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The determination of the UCR is directly affected by the percentile system. Although a health insurance policy may provide for reimbursement of major medical claims at the 80% rate (an 80/20 plan), the amount that will be paid by the insurer may depend on the specific percentile provided for in the policy. (See Chapter 4 for a more complete discussion of the UCH and percentile systems.)

In some policies, the amount of reimbursement may also be limited by both the yearly benefit maximum (the maximum amount of reimbursement available under major medical during a single calendar year) and the lifetime benefit maximum (the maximum amount of reimbursement available under the policy during a person's lifetime). Those amounts, of course, vary from policy to policy.

In addition, some insurance policies may have a separate provision for durable medical equipment. That provision relates to coverage for such equipment as manual and power wheelchairs, crutches, and walkers. Traditionally, only certain types of medical equipment have been covered by health insurance policies. Other types of equipment are generally excluded from coverage. For example, many health insurance policies provide coverage for both manual and power wheel chairs under provisions for durable medical equipment. However, other types of related equipment -- wheelchair ramps, wheelchair lifts, reduced effort steering for a car or van, a specially adapted computer, an accessible shower -- are rarely covered by health insurance policies, even though they may be directly related to a medical condition.

Preventive care -- treatment for the prevention of illnesses -- is not usually covered by traditional health insurance policies. Such policies are generally designed to pay only for the treatment of existing illnesses or conditions, rather than for their prevention. However, managed care plans often include coverage for such preventive services as routine yearly physical exams, vaccinations, and routine screening tests.

Benefits for the treatment of mental and emotional illness may be covered by a separate provision in some health insurance policies. That provision generally includes coverage for the treatment of depression, anxiety, Schizophrenia, bipolar disorder, and similar illnesses or conditions. Treatments in relation to drug and alcohol problems may also be included in that category under some insurance policies. (See Table 7 for a list of technical terms used to describe plan benefits and for the definition of each of those terms.)

There may be different rules for coverage for the treatment of mental and emotional illness, both in terms of treatment in a therapist's office (outpatient treatment for mental illness) and hospital-based treatment (inpatient treatment for mental illness). For example, some health insurance policies have tra ditionally had different yearly or lifetime benefit maximums in terms of coverage for the treatment of mental illness as com pared to coverage for the treatment of physical illness. How ever, the recently enacted federal Mental Health Parity Act requires changes in the rules related to yearly and lifetime benefit maximums for physical and mental illnesses. (See Chapter 4 for a discussion of issues related to mental health parity).

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