You’re considering a visit to a dermatologist for a skin issue you want to address. But you’re concerned: will insurance cover the visit or any procedures the dermatologist might recommend? Understanding insurance coverage can be tricky. Use the information below as a jumping-off point to get the answers you need before scheduling your appointment.
The biggest question you will face in coverage for a dermatology treatment is: Is the treatment cosmetic or medically necessary? Insurance companies will not cover cosmetic treatments, which are labeled as elective procedures. But they will cover treatments if they are deemed as medical necessities. To be considered medically necessary, the visit must be to evaluate, diagnose or continue treating a medical condition. Your general health must be affected if you do not get treatment. Every insurance provider will have a list of medically necessary treatments for your reference. Some examples of conditions will probably qualify for insurance coverage are: acne, skin cancer, psoriasis, eczema, shingles, warts, rashes, skin allergies, keloids hives, viral/bacterial/fungal skin infections and port wine stain removal. Cosmetic treatments that are unlikely to be covered by insurance include microdermabrasion, chemical peels, Botox injection, dermal fillers and CoolSculpting. Some laser treatments are covered (like for port wine stain removal), while laser treatment for hair or tattoo removal is not. Before you receive any dermatological treatment, make sure to contact your insurance company to verify that your condition qualifies as medically necessary and will be covered.
You will first need to find out if a particular dermatologist is in-network with your insurance company for you to get the most coverage as possible. You can either contact your insurance company to find out in-network providers in your area, or call a dermatology practice and find out which insurers they accept. When talking to a dermatology office, be sure to be specific about which plan you have within a particular policy. Some providers will only take insurance from certain plans within broader policies. Then, once you have decided on a dermatology practice to set your appointment up with, you will need to find out if the condition you are seeking treatment for is cosmetic or medically necessary. Many providers are happy to work with you in figuring this piece out. But, it’s best to also talk to your insurance company about treatment coverage just to make sure you are fully informed about your coverage.
Your dermatologist is considered a specialist, and many insurance companies require a referral to a specialist for coverage to take place. If your health insurance plan is a POS (point of service) or HMO (health maintenance organization) plan, you will need a referral from your primary care physician (PCP) to see an in-network specialist, like a dermatologist. If you have a PPO (preferred provider organization), you probably will not need a referral. If you have an HMO and you don’t have a referral or you decide to see an out-of-network specialist, you will probably have to pay out of pocket for your visits to the specialist. Most POS’s will still cover some out-of-network visits if you have a referral from your PCP. It’s also important to know that referrals expire. You’ll usually have 90 days to 1 year to see the specialist you were referred to, depending on the speciality.
Even if your dermatologist is in-network and your treatment is considered a medical necessity, you may need to pay a co-payment at your office visit. You may also have to pay for part or all of your visit until you meet your plan’s deductible. Once your deductible is met, your insurance company will pay for all or most of your future visits. The deductible usually resets at the beginning of the year, so getting procedures done at the end of the year once your deductible is met is a great approach (unless you need treatment immediately). You can talk to your dermatologist's office or your insurance company to find out more about co-payments and meeting your deductible. You should also talk to your dermatologist’s office about payment plans or specials they might be running. If you have an HSA (health savings account) or FSA (flexible spending account) through your insurance company, you can use the money you’ve saved to help pay for dermatology services.
Call Vanguard Dermatology in the greater New York City area to schedule an appointment. The office staff at Vanguard can answer your questions about insurance and coverage so that you’re comfortable with making an appointment with one of Vanguard’s board-certified dermatologists.