exclusion

What is an exclusion?

An exclusion is a provision in a health insurance policy that eliminates coverage for certain medical services. Excluded services are not covered by the plan, and excluded costs don't count towards the plan's total out-of-pocket maximum.

In the past, individual health insurance policies frequently contained exclusions for pre-existing medical conditions. But since 2014, as a result of the Affordable Care Act, all new individual major medical policies have been guaranteed issue and pre-existing condition exclusions are no longer allowed.

However, these policies — like all health insurance policies — still contain numerous blanket exclusions that apply to all policyholders and are detailed in the policy documents. Some examples of often-excluded services include cosmetic surgery, vasectomies, weight-loss drugs and bariatric surgery, abortion, acupuncture, dental care on a health insurance policy, etc. But some policies cover services that others exclude, so there's variation from one plan to another.

And some states have mandates that require all state-regulated plans to cover certain services — examples can include abortion, weight-loss drugs, vasectomies, and infertility treatments — so this also varies from one state to another.