Preparing for Medical Costs Not Covered By Insurance

Even if you have a robust health insurance plan, not every medical procedure or service will be covered. Below are some possible out-of-pocket expenses to be prepared for, along with a few helpful tips on how to budget and save for medical costs not covered by insurance.

Health Services

Health benefits such as elder care and dental coverage are essential for many, but many of these types of expenses are not covered by insurance. Here’s what you should know about those services:

• Elder Care 

Adults in the US aged 65 and older qualify for Medicare, the federal health insurance program. However, some aspects of elder care aren’t covered. Medicare doesn’t cover the cost of personal care, so at-home assistance with bathing, grooming, mobility and so on would need to be paid out-of-pocket or via a separate insurance policy. Long-term care insurance, for example, is specifically designed to help aging individuals or their family members contend with the cost of assisted living, nursing homes or at-home care.

If you’re planning for elder care expenses, also consider non-medical costs that aren’t covered by any kind of insurance. For example, if a move to an assisted living facility becomes necessary, you may need cash at-the-ready to cover moving expenses or pay for a realtor to handle a home sale. Alternatively, taking out a reverse mortgage is one way to borrow money against the value of a home and use it to pay for long-term care. When the home is sold, or the mortgage holder passes away, the reverse mortgage will become due.

• Dental Costs 

Dental care isn’t considered an essential health benefit for adults, meaning many insurers don’t offer dental coverage. (For children, this is an essential benefit and insurers are required to cover it). If you don’t have a health insurance plan with dental, you can opt to pay out-of-pocket for necessary procedures, or you can pay for a separate dental insurance plan. Companies will sometimes be able to offer their employees a discounted group plan.

Without insurance, expect to pay around $100-$200 for a cleaning and polish, and the same again for X-rays; around $50 or up to $4,500 for a filling, depending on the filling material; and up to $1,500 for a root canal, depending on which tooth is affected and the severity of the infection. Dentist offices know that many patients’ insurance situation varies, so don’t be shy about asking for a price list. Credit cards are a popular way to pay for out-of-pocket dental costs, but as always, make sure you’re budgeting ahead of time and staying up-to-date on credit card payments to avoid high interest rates or inadvertently lowering your credit score.

Health Procedures

When it comes to specific procedures there are some that won’t fall under your health insurance policy. If you’re considering one of the below health expenses, here’s what to know.

• Transitioning 

Many employer-sponsored insurance policies, and plans sold under the Affordable Care Act, do cover at least part of the cost of gender-affirming surgery. Most people will need to have an official diagnosis of gender dysphoria in order to qualify, and be able to prove that they’ve spent at least a year living as the gender they want to transition to. Without insurance, expect out-of-pocket costs around $2,000 per year for hormone therapy, $9,000 for top surgery, $25,000 for bottom surgery, and upwards of $50,000 for facial sculpting surgery.

The constantly changing legislation around transitional healthcare makes it difficult to predict what insurance will cover and what payment will need to be made out of pocket. Ask specific questions to your healthcare provider if you’re unclear about any aspect of coverage. In some cases, hospitals may offer a cash price for procedures that is lower than what’s charged out to insurance companies—it can’t hurt to ask! And, as you’re budgeting for the medical aspects of transition, don’t forget to prepare for additional expenses such as a wardrobe update and name change paperwork.

• Freezing Your Eggs 

The cost of freezing your eggs ranges from around $5,000 to $10,000. However, that doesn’t include additional fees related to storage, medication during egg retrieving cycles, and IVF when you’re ready to use the eggs.

Because egg freezing is usually deemed an elective procedure, it’s tough to find an insurance policy that covers it. However, it’s possible that insurers may cover parts of the cost; and in some states, including Massachusetts, insurance companies are legally obligated to offer at least some coverage for fertility treatments. For example, diagnostic testing and physician consultation will often be covered, even though cryopreservation may not. 

Check in with your insurer about what coverage you can expect. If it looks like you’ll be shouldering most of the costs without the help of insurance, you can try to find a fertility clinic that offers an installment payment plan for patients who can’t pay up-front. Another option is to take out a personal loan for this purpose. Depending on your credit, you may get a better rate and terms on a loan from a financial institution, rather than signing up for financing directly from the fertility clinic. 

• Breast Reduction

Breast reduction is typically covered by insurers when it is deemed medically necessary. This may mean that you need to prove that you are experiencing headaches, back pain and so on, and that other therapeutic interventions such as physical therapy haven’t worked.

Without insurance, the cost of breast reduction surgery runs just under $6,000. Again, it may be possible to arrange for an installment payment plan, depending on your clinic. If you’re not able to save up the required funds and wish to have the surgery right away, a credit card or personal loan can help you pay for this procedure—but be mindful of interest rates, and come up with a workable pay-back plan to reduce your overall cost.