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Your Advocacy Connection

By Jamie Long
The Passionate Patient Advocate
GolderCare Solutions, Unlimited, LLC

What Does Medical Insurance Cover?

Vast portions of the care we as a society receive are paid for by medical insurance. But other portions – perhaps just as vast – aren’t covered by medical insurance. Bills not covered by medical insurance are generally owed by us personally and are said to be “private pay.” Except for free care or charity care, care services we receive must either be paid for by insurance or privately.

So which care services are covered by medical insurance and which ones aren’t? What determines whether medical insurance pays or not?
The primary factor used to determine whether medical insurance will pay or not is whether the service rendered was medically necessary. Generally speaking, medical insurance is designed to indemnify or reimburse us for necessary medical expenses we incur. Medical necessity is the key.

The frequently unstated corollary is that medical insurance is not designed to pay for non-necessary services. Much cosmetic surgery, for example, is not medically necessary, so must be paid for out of our own pockets.

Another way of saying that medical insurance pays for medically necessary care is to say that it pays for curative care. Curative care is care that is designed to cure a disease or illness or heal an injury.

Curative care is not the only kind of care we receive, however. As indicated previously, for example, cosmetic surgery is usually not curative care. It is often helpful to look at the different types of care services we receive as phases or stages in a continuum of care.

Preventive Care. First, there is preventive care. Preventive care is designed to prevent disease or to detect it early enough that it can be successfully treated so as to avoid heavy duty curative care later. In the past, preventive care wasn’t covered by medical insurance as the disease process hadn’t progressed to the stage where curative care was necessary. Over time, however, medical insurance providers have learned that paying for some forms of preventive care up front can save them from having to pay for expensive curative care later. As a result, a number of preventive care screens and procedures are now covered by medical insurance, even though they weren’t in the past.

Curative Care. Second on the continuum is curative care. As we discussed earlier, curative care is the classic phase of the continuum covered by medical insurance.

Rehabilitative Care. Third comes rehabilitative care. This is care which comes after you have been cured. It is designed to get you back to your prior level of functioning before you were debilitated by illness or injury. Like preventive care, this care was not originally covered by medical insurance because it wasn’t medically necessary to cure you. When the insurance providers realized that debilitated people without rehabilitation are far more likely to get sick again or re-injure themselves, they decided to pay for some rehabilitative services in an attempt to save themselves from having to pay for a second round of curative care. As a result, some rehabilitative care is covered by medical insurance.

Custodial Care. Fourth on the care continuum is custodial care, often called Long-term Care. This is care which is not designed to cure us. Rather, it is designed to maintain us on a day-to-day basis by assisting us with our activities of daily living, such as eating, bathing, dressing, and a host of others. Custodial care can be delivered in different settings, including your home, an assisted living facility, or most typically, a nursing home. Medical insurance does not pay for custodial care. Custodial care is private pay. A specialized type of insurance called Long-term Care Insurance is available for purchase to assist in paying for any custodial care you might need, but it must be procured well in advance of your needing the care. Additionally, public Medicaid benefits are available for custodial care patients who run out of money with which to pay privately.

Palliative Care. Fifth comes palliative care. Generally speaking, palliative care is utilized when a disease or condition can’t be cured. Palliative care aims at treating and managing the symptoms of the incurable disease or condition without curing its underlying cause. Its purpose is to palliate the discomfort and stress caused by a chronic disease or condition and, thereby, to increase the quality of life of the patient. Until recently, most medical insurance offered little assistance paying for the cost of palliative care, but that is slowly changing. Check with your primary care physician if you wish to explore palliative care and the extent of your insurance coverage for it.

Hospice Care. Sixth and last on the care continuum is hospice care, sometimes called Comfort Care. Hospice is essentially palliative care at end of life. It is designed for an incurable illness or other terminal condition during the last 6 months of life. A physician has to certify a likely prognosis of 6 months or less, and the hospice patient makes an election to forego all, or most, curative care treatments. The object is to keep us comfortable while we are dying, not to try to cure us. Because it’s not curative care, some medical insurance won’t pay for it. But Medicare and some other providers of medical insurance do pay for it because it’s much more cost effective than expensive curative treatments at that stage of illness, which are likely to be futile anyway. And the patients aren’t subjected to unnecessary medical treatments which may only cause them to suffer.

In this day and age, medical necessity is still the central key to whether or not medical insurance will pay for care. But, as we’ve discussed, there are additional considerations which frequently factor in to favor coverage of certain phases of the care continuum. Not all insurance covers all of the phases so make sure you check with your insurance before assuming you have that particular coverage.

Jamie Long is the Chief Patient Advocate for GolderCare Solutions and can be contacted at 309-764-2273.