Health Insurance: Understanding What It Covers – familydoctor.org

Your health insurance policy is an agreement between you and your insurance company. The policy lists a package of medical benefits, such as tests, medications, and treatment services. the insurance company agrees to cover the cost of certain benefits listed in your policy. these are called “covered services.”

Your policy also lists the types of services your insurance company doesn’t cover. You have to pay for any non-covered health care you get.

Reading: What is a health insurance policy

path to better health

How do I know what services are covered?

If you already have an insurance plan and want to keep it, check your benefits to see what services are covered. Your plan may not cover the same services that another plan covers. You should also compare your plan with those offered through the health insurance marketplace. The Health Insurance Marketplace is a service that helps you shop for and compare health insurance plans. is operated by the federal government.

essential health benefits

Most insurance plans will cover a set of preventive services. this does not mean that they are free. you may still have to pay deductibles, copays, or other out-of-pocket costs.

These preventive services include immunizations and certain health screenings. If you buy a plan through the health insurance marketplace, your insurance will cover preventive services. It will also cover at least 10 essential health benefits required by the Affordable Care Act (ACA). All private health insurance plans offered in the federally facilitated marketplaces will offer the following 10 Essential Health Benefits (EHBS):

• outpatient services (outpatient care you get without being admitted to a hospital).
• emergency services.
• hospitalization (such as surgery).
• pregnancy, maternity and newborn care (care before and after the birth of your baby).
• mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy).
• prescription medications.
• rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or regain mental and physical abilities).
• laboratory services.
• preventive and wellness services and chronic disease management.
• pediatric services, including oral and vision care (but adult dental and vision coverage is not ebs).

State-run marketplaces are also required to offer 10 ehbs, but the list of benefits may differ from those offered by federally-facilitated marketplaces. plans may offer additional coverage.

preventive services

Preventive services can detect disease or help prevent disease or other health problems. The types of preventive services you need depend on your gender, age, medical history, and family history. all health insurance marketplace plans must cover the following without charging a copay:

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for all adults:

• One-time abdominal aortic aneurysm screening (for men ages 66-75 who have ever smoked).
• screening and counseling on alcohol abuse.
• use of aspirin for adults aged 50 to 59 years who would benefit from it.
• blood pressure test.
• cholesterol screening for adults at higher risk.
• colorectal cancer screening for adults ages 50 to 75.
• depression detection.
• diabetes (type 2) screening for overweight adults ages 40-70.
• dietary counseling for adults at risk of chronic diseases.
• fall prevention for adults over 65.
• Hepatitis B screening for people at higher risk.
• Hepatitis C screening for people at higher risk.
• HIV screening.
• immunization shots.
• Lung cancer screening for adults ages 55 to 80 who are at increased risk of lung cancer due to smoking.
• obesity screening and counseling.
• sexually transmitted infection prevention counseling for people at increased risk.
• preventive statin drug for high-risk adults 40 to 75 years old.
• Syphilis screening for people at higher risk.
• screening for tobacco use.
• tuberculosis screening for adults at higher risk.

for women who are pregnant or may become pregnant:

• screening for anemia.
• comprehensive breastfeeding counseling and support.
• contraception.
• folic acid supplements.
• screening for gestational diabetes.
• Gonorrhea screening for all women at increased risk.
• Hepatitis B screening for pregnant women.
• prevention and detection of preeclampsia.
• rh incompatibility detection.
• syphilis detection.
• expanded tobacco intervention and counseling for pregnant women who use tobacco.
• screening for urinary tract infections or other infections.

Other covered preventive services for women:

• breast cancer genetic testing counseling for women at increased risk.
• Breast cancer screening mammograms every 1 to 2 years for women over age 40.
• Counseling for breast cancer chemoprevention.
• screening for cervical cancer. (This includes a Pap test every 3 years for women ages 21 to 65.)
• screening for chlamydia infection.
• diabetes screening.
• screening and counseling on domestic and interpersonal violence.
• screening for gonorrhea.
• HIV screening and counseling.
• osteoporosis screening for women over 60 years of age.
• Rh incompatibility screening tests.
• advice on sexually transmitted infections.
• syphilis detection.
• screening and interventions for tobacco use.
• detection of urinary incontinence.
• Well-woman visits for women under age 65.

Children’s preventive health services (and when they should be provided) depend largely on age. To learn more about what services may be covered for your child, see a complete age-appropriate list at healthcare.gov.

what is a medical necessity? is that different from a covered service?

Please note that a medical necessity is not the same as a medical benefit. A medical necessity is something that your doctor has decided is necessary. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your doctor may decide that you need medical care that is not covered by your insurance policy.

Insurance companies determine what tests, medications, and services they will cover. these options are based on your understanding of the types of health care most patients need. Your insurance company’s choices may mean the test, medication, or service you need is not covered under your policy.

what should I do?

Your doctor will attempt to become familiar with your insurance coverage in order to provide you with covered care. however, there are so many different insurance plans that it is not possible for your doctor to know the specifics of each plan. By understanding your insurance coverage, you can help your doctor recommend medical care that is covered under your plan.

• Take the time to read your insurance policy. it’s best to know how much your insurance company will pay before you get a service, test or fill a prescription. Some types of care may need to be approved by your insurance company before your doctor can provide them.
• If you still have questions about your coverage, call your insurance company and ask a representative to explain them.
• Remember that your insurance company, not your doctor, makes the decisions about what will and will not be paid.

things to consider

other costs

Your insurance company may ask you to pay for some of the care you receive. This is often called cost sharing because you share or pay some of the costs and your insurance company pays the rest. there are different types of costs that you could pay. these include:

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Copayment: This is sometimes called a “copayment.” It is usually a fixed amount you pay for a visit, test, or medication. copays are typically lower for family doctors than for specialists.

deductible: This is the amount of money you must pay each year before the insurance company covers all the remaining costs. This is often referred to as “meeting your deductible.” If you’re in good health and don’t use health care often, it may make sense to have a high deductible and low monthly cost for insurance. however, if you get sick, your costs may be higher.

Coinsurance: After you’ve met your deductible for the year, some insurance companies still require coinsurance. this is the percentage of the cost that you will still pay for some services.

This can all be confusing. It’s important to know what your coverage plan offers before you sign up. call your insurance company if you don’t understand, or talk to your doctor to get answers to your questions.

what if my doctor recommends care that is not covered by my insurance?

Most of the things your doctor recommends will be covered by your plan, but some may not. When you have a test or treatment that isn’t covered, or fill a prescription for a drug that isn’t covered, your insurance company won’t pay the bill. this is often called “denying the claim.” You can still get the treatment your doctor recommends, but you’ll have to pay for it yourself.

If your insurance company denies your claim, you have the right to appeal (challenge) the decision. Before you decide to appeal, learn about your insurance company’s appeal process. this should be discussed in your plan manual. Also, ask your doctor for their opinion. If your doctor thinks it’s okay to file an appeal, they may be able to help you through the process.

questions for your doctor

• Are there certain types of insurance you don’t accept?
• What type of coverage is most important to me and my family?
• Are you in my insurance company’s provider network?

resources

us centers for medicare and medicaid services, healthcare.gov: preventive health services

usa centers uu. for medicare and medicaid services, healthcare.gov: what health insurance plans on the marketplace cover

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