Questions/Tips Insurance

Health Insurance: Riders to Expand, Limit, or Exclude Coverage

(6/5/2012) A health insurance policy will stipulate what health care services are covered, how much you will pay for them, and which providers you can see to obtain these services at these costs. But that’s not the whole story.

Riders are amendments to your health insurance policy that expand, set limits, and even dictate exclusions to this coverage. Riders vary by company and policy, but are also very specific to you and your individual health. These riders will affect your monthly premiums, and may indicate additional costs you may need to pay over the life of your policy.

Riders can exist to provide additional coverage beyond that specified in your basic policy. Typically, you will pay additional for these riders, but will not need to draft a new policy or rewrite an existing policy. If you are concerned about coverage of specific services or situations, riders can be a good option. Examples include the long-term care rider, which can cover long-term care, unskilled nursing, respite care, durable equipment, and therapy, and the extended stay rider, which expands the amount of time of hospitalization per incident.

The most common limitation of coverage is for “pre-existing conditions.” If you have a current medical condition, called a pre-existing condition in health insurance lingo, your plan will usually include a rider that limits your coverage for care related to that condition for a certain amount of time (usually a year). If you have a wrist injury, for example, your health insurance company may limit the amount they will provide for imaging services, surgeries, prescriptions or other care for that pre-existing condition. After the time period is complete, companies will cover all services normally, no matter if it is for your pre-existing condition.

These riders will deny coverage for illnesses, certain medications, or entire classes of services. In the case of pre-existing conditions, while some policies will merely limit the amount of coverage, others will exclude these conditions from coverage completely. When this happens, companies often offer addendum policies specifically for that pre-existing condition. Usually these come with hefty premiums, but may offer an important alternative to paying out-of-pockets fees for conditions that require a lot of care.

Important to remember with health insurance is the need to read and understand the policy and its riders. These are just a few instances of expansions, limitations and exclusions: know what coverage you do have, and what coverage is limited or outright excluded, to avoid surprise costs and hidden fees.

For additional reading:

Typical Health Insurance Limitations and Exclusions:

Pre-Existing Condtions: Understanding Exclusions and Creditable Coverage:

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