Health Insurance: Understanding What It Covers
Your health insurance policy is an agreement between you and your insurance company. The policy lists a package of medical benefits such as tests, drugs, 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 kinds of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you receive.
Path to improved health
How do I know which services are covered?
If you already have an insurance plan and want to keep it, review your benefits to see which 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. It is operated by the federal government.
Essential Health Benefits
Most insurance plans will cover a set of preventive services. This does not mean they are free. You may still need to pay deductibles, copayments, or other out-of-pocket costs.
These preventive services include shots and certain health screenings. If you buy a plan through the Health Insurance Marketplace, your insurance will cover the 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 federally facilitated marketplaces will offer the following 10 essential health benefits (EHBs):
Ambulatory patient services (outpatient care you get without being admitted to a hospital).
Hospitalization (such as surgery).
Pregnancy, maternity, and newborn care (care before and after your baby is born).
Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy).
Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills).
Preventive and wellness services and chronic disease management.
Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t EHBs).
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 can detect disease or help prevent illness or other health problems. The types of preventive services you need depend on your gender, age, medical history, and family history. All plans from the Health Insurance Marketplace must cover the following without charging a copayment:
For all adults:
Abdominal aortic aneurysm one-time screening (for men ages 66-75 who have smoked).
Alcohol misuse screening and counseling.
Aspirin use for adults 50-59 years who would benefit from it.
Blood pressure screening.
Cholesterol screening for adults with higher risk.
Colorectal cancer screening for adults 50-75 years.
Diabetes (Type 2) screening for adults 40-70 years who are overweight.
Diet counseling for adults with risk of chronic disease.
Fall prevention for adults 65 years and over.
Hepatitis B screening for those at increased risk.
Hepatitis C screening for those at increased risk.
Lung cancer screening for adults 55-80 years who are at increased risk for lung cancer due to smoking.
Obesity screening and counseling.
Sexually transmitted infection prevention counseling for those at increased risks.
Statin preventive medication for adults 40-75 years at high risk.
Syphilis screening for those at increased risk.
Tobacco use screening.
Tuberculosis screening for adults at increased risk.
For pregnant women or women who may become pregnant:
Breastfeeding comprehensive support and counseling.
Folic acid supplements.
Gestational diabetes screening.
Gonorrhea screening for all women at increased risk.
Hepatitis B screening for pregnant women.
Preeclampsia prevention and screening.
RH incompatibility screening.
Expanded tobacco intervention and counseling for pregnant women who use tobacco.
Urinary tract or other infection screening.
Other covered preventive services for women:
Breast cancer genetic test counseling for women at increased risk.
Breast cancer mammography screenings every 1 to 2 years for women over age 40.
Breast cancer chemoprevention counseling.
Cervical cancer screening. (This includes a Pap test every 3 years for women 21-65 years.)
Chlamydia infection screening.
Domestic and interpersonal violence screening and counseling.
HIV screening and counseling.
Osteoporosis screening for women over 60 years.
Rh incompatibility screening follow-up testing.
Sexually transmitted infections counseling.
Tobacco use screening and interventions.
Urinary incontinence screening.
Well-woman visits for women under 65 years.
What is a medical necessity? Is that different from a covered service?
Keep in mind 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 might decide that you need medical care that is not covered by your insurance policy.
Insurance companies determine what tests, drugs and services they will cover. These choices are based on their understanding of the kinds of medical care that most patients need. Your insurance company’s choices may mean that the test, drug, or service you need isn’t covered by your policy.