Coverage Gaps: What They Are and How to Dodge Them

One of the most frustrating parts of dealing with health insurance is thinking you’re covered — until you’re not.

That’s a coverage gap. And they can get expensive, fast.

Here’s what you need to know so you don’t get blindsided:

1. What is a Coverage Gap?

A coverage gap is any situation where you thought something was covered... but it’s not. That could mean:

• A doctor you thought was in-network isn’t.
• A medication isn’t on your plan’s approved list.
• You assumed you had mental health coverage but don’t.

These kinds of gaps usually don’t show up until you’re at the pharmacy counter or getting a surprise bill.

2. Common Reasons Gaps Happen

• Picking a plan without understanding the fine print
• Buying a plan based solely on price
• Getting sold something by an agent who didn’t ask the right questions
• Assuming all plans cover the same stuff (they don’t)

3. How to Avoid Them

• Ask specific questions when comparing plans. “Is [this provider] covered?” “Are [these meds] included?”
• Always double-check the network and drug formulary (fancy term for the list of meds they’ll pay for)
• Work with someone who actually takes time to understand your situation — not someone reading off a script

4. What to Do if You Already Have a Gap

Don’t panic. There may be supplemental options or better-fitting plans that can fill in the holes — especially if you qualify for a Special Enrollment Period. Reach out and we’ll talk through your options.

At Wolfe Health, we believe no one should be surprised by what isn’t covered.

Let’s make sure you get a plan that fits — and doesn’t leave you guessing when it matters most.

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