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How should I prepare if I deliberately choose to receive an excluded benefit?

There are often circumstances when you and your physician consciously decide that the best alternative treatment for you under your particular circumstances – a test, medication, or some other service or product – happens to be an excluded benefit under your insurance plan. Remember – nobody can deny you any treatment. Just because it’s an excluded benefit doesn’t mean it’s not the right treatment for you; it just means your insurance plan won’t pay for it.

Once you decide that the excluded benefit is your best option, the key is to make every effort to understand what the reasonable and customary fee might be for that service or product and either negotiate that rate with your provider of choice (just as you would with an Out of Network Provider, even if your provider of choice is in network), or find a provider willing to provide it at that price. Painful? Perhaps. But worth it when you remember that you would normally be billed the Charge Master or Provider Charges for that product or service, which is often 2-10x the reasonable and customary fee.

If you haven’t yet met your deductible for the year, AND you have negotiated with the provider of the excluded benefit in advance to charge you (or accept) an amount at or close to a reasonable and customary fee for that service, then you may be roughly financially neutral relative to a comparable included benefit since if you used the included benefit you’d be paying out of pocket anyway (since you hadn’t yet met your deductible).



Next:  Everyone just LOVES to get a surprise bill, right?  Or maybe not.  Read on for some pointers on how to avoid charges for unexpected, unnecessary, or unwanted out of network providers or excluded benefits.


Remember:  We coach, support, educate, and empower.  We illuminate options you may not have known you had.  But we don't decide what's right for you in your unique circumstances; only you can do that.  And we don't provide medical, financial, or legal advice; nor do we replace the valuable counsel of those who do.