Other Benefit Limitations That You Should be Aware Of

Be aware of benefit limitations. Some benefits are limited by a specific number of days, visits or specific dollar amount per "year". It is important to understand if your policy is set-up based on a calendar year or a contract year.

Insurance Policy Questions

A calendar year runs from January 1st to December 31st. A contract year begins when your policy is activated and runs through the following year ending on the last day of the month in which it was purchased. If your policy became effective in June of this year and is based on a contract year, it will be effective through the end of June the following year.

In general, medical policies limit the skilled nursing facility services to 100 days per year. Therapy visits such as physical therapy, occupational therapy or speech therapy are limited to a set number of visits per year. Chiropractic visits may be combined with the number of physical therapy visits or be independent, but are typically limited to a set number of visits per year also.

It is important to read the limitations for your therapy visits as many of them will state "additional visits as authorized based on medical necessity." In other words, you may be able to obtain additional visits if it meets your insurance provider's definition of medical necessity.

Your durable medical equipment (DME) benefit may be limited by a fixed dollar amount per year. It is very easy to go over this amount! An insulin pump alone, costing several thousand dollars, is capable of using most (if not all) of your DME dollar amount.

A quick reference to these limitations can be found in the front table of your benefit booklet (evidence of coverage and disclosure form). For a more detailed outline of the limitations, you will want to look up the specific service/benefit.

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