What Do Insurance Companies Cover

¶ … Coin: Heads Insurance options available to the patient depend upon the policy held by the patient and what is covered by the insurer. Some insurance companies will cover life-saving operations, while others will not (Roizen, 2015). Yet even if the operation is covered, there may be a substantial deductible that will have to paid out of pocket; again, this all depends on the type of insurance coverage that the individual possesses.

In a time like this, it is difficult to think of finances especially when a loved one's life is at stake. Fortunately, even if the deductible is high, or -- in a worst case scenario -- the insurance company will not cover the operation, there are hospitals that will provide financial aid to applicants. At the same time, government insurance options are available, such as Medicare and Medicaid.

If the patient is 65 years of age or older, he may already be eligible for Medicare, which is a federally funded program to assist persons in old age with medical bills. Medicaid is funded by both state and federal governments and is available for low income families whose household earnings are under a projected threshold. In a family of 4, that threshold is currently around $30,000 depending upon one's state, which sets limits on the income amount.

If the patient fits into either of these categories, they are measures that are worth exploring. If not, the previous possibilities of having coverage or of applying for financial aid through the hospital may be pursued. In many cases, hospitals such as Mercy Health offer financial assistance to individuals even if they have insurance coverage but still need help meeting the deductible. In any case, there are options available for this patient.

The main problem that the patient is likely to experience, however, is that the procedure recommended by the doctor is most typically going to be perceived as an experimental procedure that has not been sufficiently or adequately tested over time in order to meet the criteria for insurance coverage.

Insurance companies usually will not choose to cover a life-saving procedure that has only been written about in an academic journal and not been time-honored and proven success over a series of clinical trials and become standard practice or medicine within the medical community (Williams, 2016).

With the cost of premiums set to go up around the country, due to the losses sustained by participating insurance brokerages in the Affordable Care Act, deductibles are most likely to rise as well, as insurance companies seek to make up for the lost ground in recent years (Durden, 2016). This will present further complications for families and will be another issue to consider, should the patient decide that seeking coverage may be the best option, if none is currently possessed by the patient.

Thus, the family's next steps should include the following: contact the family's insurance provider (if the family has one) and discuss the options available to the father and gather information as to whether the provider will cover the recommended procedure; if not, find out if the provider will cover the time-tested, standard protocol procedure. This information will help the family to better know what financial courses are open to them.

If the insurer does not offer any coverage whatsoever, or if the family is uninsured privately, the next step would be to look into Medicare and/or Medicaid. Certain parameters will have to be met (age for Medicare and low-income for Medicaid).

If these conditions are not met by the family, an alternative here is to find a hospital that offers financial aid for families, such as Mercy Health, which is a nationwide hospital group that does have a substantial financial aid program that covers families who earn up to 400% of the federal income poverty level (thus if the household grosses 4x the poverty level set by the federal government for a 4 person household, the family will still be able to receive some financial assistance from the hospital -- not 100% of costs but at least 50% of costs).

When entering into the discussion with the hospital, it is important to ask whether the recommended procedure would be one that is open for coverage through the hospital's financial assistance program (as some operations are outsourced to private practitioners who have their own billing system established). If the operation is outsourced, it is necessary to find a private practitioner (in specialized medicine, no doubt) who is capable of performing the procedure and who offers a financial assistance program for persons not covered by insurance.

A Google search of practitioners who perform the recommended procedure will produce a number of options for follow-up and the family should set about discussing the situation with providers and practitioners as soon as possible, as these are practical.