What does health insurance cover?

Getting health insurance is a great way to safeguard your finances and well-being in the event of an unexpected illness or injury. 

So what does health insurance cover? Health insurance generally covers hospital and inpatient services, preventive care, doctor visits, and prescription drugs. It may also cover certain specialist services, such as physical therapy or mental health counseling. 

But health insurance does not always cover everything. Read on to learn more about what your insurance covers and does not cover whether you have individual health insurance or an employer-provided plan.

What It Means to Be “Covered”

What is covered by health insurance and what does it mean to be covered? Regarding health insurance, being “covered” means that your insurer will pay for a portion of the services you receive. Your deductible and copays typically determine this portion. In addition, your doctor has to be within your insurance network for your insurer to cover the services.

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What does health insurance cover?

What does health insurance do for you? Health insurance coverage can be a confusing topic. It’s good to understand what services, procedures, and treatments are covered by your health insurance policy to make the most of it. 

Here is a comprehensive list of the services, procedures, and treatments usually covered by health insurance plans. 

Doctor Visits & Inpatient Services

A health insurance policy will typically cover the cost of doctor visits and inpatient services. These include hospital stays, emergency room visits, and visits to specialists, such as pediatricians, obstetricians/gynecologists, psychiatrists, and more. 

While you may still have some out-of-pocket expenses like copayment, coinsurance, and deductible costs, your insurance will typically pay most of your medical bills as long as they are deemed medically necessary. The care provided should also be within your network of providers.

Preventative Care

Health insurance covers preventive care to help keep you healthy. It is available at no cost and includes services like checkups, screenings, and vaccines. There are three categories of preventative care: all adults, women, and children.

For all adults, services include:

• Abdominal aortic aneurysm
• Alcohol misuse screening and counseling
• Blood pressure screening
• Cholesterol screening
• Colorectal cancer screening (adults 45 to 75)
• Depression screening
• Diabetes (Type 2) screening (overweight or obese adults 40 to 70 years)
• Diet counseling
• Hepatitis B & C screening
• HIV screening
• HIV prevention medication
• Immunizations
• Sexually transmitted infection (STI) prevention counseling
• Tuberculosis screening

For women, services include:

• Screenings for breast and cervical cancer
• Well-woman visits
• Contraceptive counseling and supplies
• HIV prevention medication
• STI and urinary tract infection screening
• Gestational diabetes screening
• Birth control
• Folic acid (for women who may become pregnant)
• Rh incompatibility screening

For children, services include:

• Infant and child immunizations
• Autism screening
• Sickle cell anemia screening
• Obesity screenings and counseling
• Hearing, vision, and dental screenings
• Lead poisoning screening
• Developmental assessments
• Hypothyroidism screening

This is just a sample of the preventive care services covered by insurance. It is important to know what your plan covers, as this will vary from plan to plan.

Essential Health Benefits

In addition to the services listed above, all health insurance plans must cover these ten essential health benefits (EHBs).

• Ambulatory patient services
• Emergency services
• Hospitalization
• Laboratory services
• Maternity and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Preventive and wellness services
• Pediatric services, including oral and vision care
• Rehabilitative and habilitative services and devices

It’s worth noting that these 10 benefits of health insurance don’t cover dental and vision care for adults. However, they may be added as additional riders or benefits.

Pre-existing Conditions

Another component of health insurance is coverage for pre-existing conditions. Under the Affordable Care Act, this includes any medical condition that existed before enrolling in the plan. This means that all health insurance plans must cover these pre-existing conditions. 

No one can be denied coverage or charged a higher premium due to an existing medical condition. Read more about health insurance plans for people with pre-existing conditions.

Prescription Drugs

Prescription drugs are a crucial component of health insurance coverage. Most plans will cover a range of prescription drugs, although the detailed list of covered medications may vary from plan to plan. 

Contact your health insurance provider to get a list of covered medications and information about formulary tiers and copays.

What does health insurance not cover?

While health insurance usually covers many medical services, it does not cover a few things. These include:

Cosmetic Surgery

Cosmetic surgery is any surgery done to improve appearance rather than treat any underlying medical condition. This includes facelifts, liposuction, Botox injections, and breast augmentation. This type of surgery is generally not covered by health insurance.

Unless these procedures are deemed medically necessary due to an underlying medical condition or injury — such as reconstructive surgery after an accident — you will be responsible for the full cost out-of-pocket. 

Experimental Treatments & Medications 

Health insurers do not usually cover experimental treatments and medications because they have not been approved by the FDA yet as safe and effective treatments for a specific condition or disease. 

In some cases, insurers will cover experimental treatments if a doctor has recommended them as a potential solution to a particular health issue. 

However, checking with your insurer before undergoing any experimental treatment or medication is best to ensure it is covered under your policy.  

Uncovered Prescription Drugs

Some prescription drugs, particularly those not deemed medically necessary for treating a specific condition, are not covered by health insurance. 

Some insurers, for example, do not cover drugs used to treat non-life threatening conditions such as hair loss or erectile dysfunction.

Infertility Treatments

Infertility treatments are not usually covered by health insurance, as they are considered elective procedures. These include treatments like in-vitro fertilization (IVF) and intrauterine insemination (IUI). 

However, some states, including Massachusetts and New York, have laws that require insurers to cover fertility treatments, so check with your state’s insurance commissioner to find out if you are eligible.

Alternative Treatments 

Health insurance plans don’t always cover alternative treatments like acupuncture and chiropractic care. 

Generally, these treatments must be medically necessary or prescribed by a physician to be eligible for coverage. 

Additionally, some health insurers will only cover a certain percentage of the cost or up to a specific dollar amount per session.

Weight Loss Programs 

Many health insurance plans do not cover weight loss programs like diet and exercise or bariatric surgery. Most health insurance plans also don’t cover gym memberships or personal trainer costs. 

What if my insurance doesn’t cover a procedure that I need? 

It can be frustrating when you need medical attention, and your insurance won’t cover it. So what are some reasons why your insurance might not cover a particular procedure or service, and what can you do to get the treatment you need? Let’s take a look.

Medical Necessity Denial

Sometimes, a procedure or treatment is not covered because the insurer determines that it is not medically necessary for your particular situation.

If this happens to you, you can appeal the decision by submitting a letter of medical necessity to your insurer. The letter should include information about why you need the procedure or treatment and why it is a medically necessary part of your treatment plan.

Incorrect Referral or Prior Authorization

Health insurance plans may also deny coverage if you did not receive a referral or obtain prior authorization from your primary care doctor before receiving the service. 

For example, if you receive a referral for a specialist but do not obtain prior authorization from your primary care doctor, the insurer may deny coverage for the services.

In this case, you should contact your primary care doctor and ask them to submit a referral or prior authorization request on your behalf.

You Received Care From an Out-of-Network Provider

Your insurer may not cover the services if you receive care from an out-of-network provider. Health maintenance organizations (HMOs) and exclusive provider organizations (EPOs) usually only pay for care from doctors and hospitals in their networks.

If you find yourself in this situation, you can ask the provider if they will accept your health plan’s in-network rate. 

Many providers may be willing to do so if you provide proof of insurance. But if not, you will have to look for an in-network provider or pay out of pocket for the services.

Other Mix Ups or Errors

Sometimes, a claim can be denied due to an administrative error. For example, incorrectly entered information on claims forms when submitting them for payment — or other mix-ups with enrollment information between employers and insurers confusing who should pay for certain services or medications prescribed by doctors (this happens more often than people realize). 

If this happens to you, it is important to contact your insurer promptly and provide documentation that shows the error. 

If the mistake is corrected quickly, you may be able to get coverage for the procedure or treatment.

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Other Costs Associated with Health Insurance

In addition to the treatments and services covered by health insurance, you may also be responsible for certain out-of-pocket costs. These can include:

• Copayments: These are the fixed fees you pay for certain services or medications.
• Deductibles: These are the annual amounts that you must pay out of pocket before your insurance starts paying for services.
• Coinsurance: This is the percentage of medical expenses you must pay after you reach your deductible.

Before signing up for a health insurance plan, read the terms and conditions carefully and become familiar with any out-of-pocket costs you may be responsible for to avoid surprises. Find out the best comprehensive healthcare providers. 

Questions You Should Ask Your Doctor About Health Insurance Coverage

Before receiving any treatment or services, talk to your doctor about what your health plan covers and any additional costs you may be responsible for. Here are some questions you should ask them:

• Are you in-network with my health plan?
• Is the treatment I need covered by my plan?
• What type of insurance do you not take?
• Do I need a referral or prior authorization for this service?

These questions can help you avoid any unexpected costs or potential coverage denials.

What does medical insurance cover: Final Thoughts

The importance of asking “what does insurance cover?” and understanding what is covered by your health insurance plan cannot be understated. 

Knowing the right questions to ask and doing your due diligence upfront can help take a lot of the guesswork out of deciding what services are covered and which ones aren’t. 

It’s also important to understand what it means to be “covered” by health insurance and learn about the benefits of having the right plan.

It’s essential to determine if your plan covers a procedure or treatment you need before considering it. Many insurance companies have lists of in-network providers and treatment facilities that offer cost savings for their customers when receiving care.

Always ask questions about what is covered before committing to any healthcare service. This way, you can avoid unnecessary financial concerns and get the help you need most.

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