Health insurance companies can absolutely limit medical treatment options for services which they deem to not be medically necessary. Each plan provider should have and make available to you an Explanation of Benefits (EOB) in either electronic or print form. You can also often contact a benefits specialist who can explain to you what is and is not covered by your plan.

Shrinking Networks of Medical Treatment Providers

One of the most significant ways in which a health insurance company limits medical treatment options is by significantly narrowing the choice of doctors and hospitals. One of the major goals of Obamacare was to keep health-care costs low, but in order to achieve that, insurance companies are leaving some of the nation’s top hospitals out of their covered networks. If you had previously been going to John’s Hopkins for cancer care, you may have suddenly been forced by your insurance to go to a county hospital instead, regardless of the drop in quality of care.

These smaller networks of doctors and hospitals have also produced quite a backlash, with some providers suing due to a loss of business. One of the unintended side-effects of the Affordable Care Act is what some describe as a two-tiered health care system: those with Obamacare plans purchased on the exchange market end up with fewer hospitals and medical treatment service providers, and those with plans through their employers have what most Americans had previously been used to: wide networks worked out privately between their insurance providers and servicers.

Appealing Health Plan Decisions

If a treatment option is denied, however, the Affordable Care Act has thankfully worked in a system for appealing an insurance company’s denial of coverage. If coverage is being denied to you, you can request that they conduct an internal review and if the review deems the coverage to not be covered, they must explain why within 72 hours. If you disagree with their findings, you have the right to have it examined by an independent third party agency which has the right to overrule the insurance company and force it to provide coverage. External reviews have a 60-day window for review and completion.

It’s important to keep in mind that the health insurance company is the ultimate arbiter of what is considered to be “required or necessary care,” not your medical provider or doctor. Always check with your insurance representative before undergoing any treatment to ascertain whether it is considered necessary and thus covered by your insurance plan.

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