It is important to be informed about what health insurance covers and what might not be so straightforward. You may sign up for California health insurance only to be surprised when you incur big bills that won’t be reimbursed. Avoid surprises with our mini-tutorial on what health insurance may not cover.

Doing something against the law

Did you know that your insurer may not reimburse health care costs if it involved your doing something that is against the law?  Break your leg while dusting a top shelf and it’ll be covered. If you break your leg while burglarizing a home, it is probably not going to be covered.  This little known exclusion is further motivation to stay within the confines of the law, if you need further incentive.

Not all prior authorization sticks

Here’s something that may shock you: Prior authorization does not mean a California health insurance plan—or any plan at all– will cover an expensive procedure. You may wonder why not. That’s because there is usually a clause that says benefits are subject to medical necessity and your eligibility. Your insurer could decide after the procedure that it wasn’t necessary and refuse to reimburse—even though it pre-authorized it. There are usually avenues of appeal, but this can happen and you may end up paying out of your own pocket.

Nursing home care

Long-term care is usually not covered under private health insurance or by Medicare. That’s why many Americans buy special long-term care policies.   A stay in a nursing home for rehabilitation after a stroke or bone break may well be covered. But if you can no longer care for yourself and require custodial care, you will not be covered.  It all revolves around the reason you need the nursing home. If you are trying to regain skills that you have a chance of getting back, then the stay may be covered for a limited amount of time.  But there isn’t much chance of custodial care being covered.

Travel shots

Frequent travelers to exotic lands know that travel vaccinations are paid for out of your own pocket. Let’s say you need a tetanus shot because you stepped on a rusty nail on a walk. That is covered by your California health insurance. But if you need a vaccine for some exotic disease you might encounter in Africa, open your wallet, as it won’t be covered.