CAMLAW: Complementary and Alternative Medicine Law Blog

Insurance caps on high-cost health care limit reimbursement

In addition to limitations on therapies considered "medically unnecessary" or "experimental," many insurance policies limit patients' reimbursement opportunities. The "medically necessary" requirement and "experimental therapy" exclusion have been applied in the past to bar patients from obtaining insurance reimbursement for CAM therapies. As for those therapies that are reimbursed, whether conventional or complementary, caps on reimbursement can also be problematic. Cancer patients can be particularly affected by these insurance policy limits:
It's not unusual to see lifetime benefit limits of $1 million or $2 million on health coverage; about half of employer-sponsored health plans have them, according to the Kaiser Family Foundation. But patient advocates say they're now seeing lifetime limits of just $50,000 or $100,000 in some cases. More patients are encountering other limits for certain products and services, too. Plans may cover only a certain dollar amount for outpatient services, for example, or limit coverage to a dozen radiation sessions. And many plans, while not technically capping drug coverage, place cancer drugs in higher formulary "tiers" that require patients to pay a percentage of the total cost rather than a straight copayment. Faced with the possibility of financially crippling bills for these drugs, which can cost several thousand dollars a month, some patients go without.
The bottom line: insurance policies need to be carefully scrutinized for their basic terms, including limits on lifetime reimbursement as well as limits on annual coverage for specific therapies or conditions.
The Law Offices of Michael H. Cohen offers corporate legal services, litigation consultation, and expertise in health law with a unique focus on holistic, alternative, complementary, and integrative medical therapies. The law firm represents medical doctors, allied health professionals (from psychologists to nurses and dentists) and other clinicians (from chiropractors to naturopathic physicians, massage therapists, and acupuncturists), entrepreneurs, hospitals, and educational organizations, health care institutions, and individuals and corporations.

Michael H. Cohen is Principal in Law Offices of Michael H. Cohen and also President of a nonprofit organization exploring legal, regulatory, ethical, and health policy issues in the judicious integration of complementary and alternative medical therapies (such as acupuncture and traditional oriental medicine, chiropractic, naturopathic medicine, homeopathy, massage therapy, energy healing, and herbal medicine) and conventional clinical care. Michael H. Cohen is author of books on health care law, regulation, ethics and policy dealing with complementary, alternative and integrative medicine, including Healing at the Borderland of Medicine and Religion, Complementary and Alternative Medicine: Legal Boundaries and Regulatory Perspectives (1998), Beyond Complementary Medicine: Legal and Ethical Perspectives on Health Care and Human Evolution (2000), and Future Medicine: Ethical Dilemmas, Regulatory Challenges, and Therapeutic Pathways to Health Care and Healing in Human Transformation (2003).
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Health care and corporate lawyer Michael H. Cohen has been admitted to the Bar of California, Massachusetts, New York, and Washington D.C. In addition to qualifying as a U.S. attorney, he has been admitted and to the Bar of England and Wales as a Solicitor (non-practicing). For more information regarding the law practice of attorney Michael H. Cohen, see the FAQs for the Law Offices of Michael H. Cohen. Thank you for visiting the Complementary and Alternative Medicine Law Blog.
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