Health Insurance Covers What? How to Find Out What You’re Covered For


If you’ve ever wondered, “my health insurance covers what healthcare services?” then you’ve come to the right place.

As a responsible, healthy adult, you probably know that a key to staying healthy is to be active every day, with at least 150 minutes of physical activity each week. A healthy diet is also a must, and families should visit their doctors at least once each year.

But in addition to these common-sense health guidelines, it’s imperative that families and individuals have a good health insurance plan. You never know when someone will get sick or hurt unexpectedly, and when that happens, you need to make sure your health insurance covers what you need from it.

In this article, we’ll go into detail about why you need to be insured; what treatments and services are most often covered by health plans; and how you can find out if your particular health insurance covers what you need, from vision care to prenatal services.

Why You Need Health Insurance

If you’re a typically healthy person who never seems to get sick, you may wonder why health insurance is so important. Perhaps you can afford to pay for teeth cleanings at your local dentist out of pocket. Maybe you’re in your 20s, and the thought of needing healthcare for a critical illness seems completely foreign to you.

Although this is the case for many people, the conclusion that health insurance is unnecessary is simply flawed. For generally healthy people, health insurance isn’t for covering expected, routine medical care (although checkups are important and covered by many health plans). Health insurance is for getting the best healthcare possible when you get sick or hurt unexpectedly.

For example, no one expects to break their leg from slipping on an ice-covered stairway. But when it happens to you, that’s exactly when you’ll realize how important health insurance is — even for healthy people.

You may believe that, if you did get injured, you could pay for your own medical are yourself without the aid of insurance. However, it’s easy to underestimate the cost of healthcare. You may have a few thousand dollars in the bank, but that won’t scratch the surface if you unexpectedly require cancer treatments. And don’t assume it can’t happen to you just because it hasn’t yet. No one intends to get sick, and it often happens when you least expect it.

With the right health plan, you can save money on important healthcare services, even before meeting your plan’s deductible. If your plan is a PPO, HMO, or EPO and purchased through the platform, you can save hundreds of dollars in medical costs from a network of care providers. This is because insurance companies negotiate discounts with care providers on your behalf. So even if the care you need doesn’t quite meet your deductible, you can still save a lot of money that you would have lost had you been uninsured. Health insurance covers what you would normally struggle to pay for, protecting you from high medical costs.

Although insurance is most important for treating unexpected illnesses and injuries, it’s also beneficial for routine healthcare. Preventive care like vaccines, screenings, and checkups are covered by many health plans, and sometimes you don’t even have to meet your deductible first. And thanks to the discounts often provided by in-network providers, you can save a lot of money on routine care even when you do have to pay. For example, you may be able to get a flu shot that costs $40 for someone without insurance for just $25. Or you may get a $150 checkup for just $85 from a doctor in your health plan network.

Whether you’re almost due for a yearly checkup or preparing against the possibility of needing emergency spine surgery, these are some of the biggest benefits of having medical insurance. Even young, healthy people should have a health insurance plan.

Health Insurance Covers What Things: Common Health Coverage

No discussion of the benefits of health insurance would be complete without showing that health insurance covers what you need it for. Of course, what your health insurance will cover depends mostly on your plan and provider. Different insurers serve different groups, and various plans exist depending on your budget, needs, and preferences. It’s important when you sign up for a health plan to make sure the health insurance covers what your needs are.

However, all good health insurance plans have some things in common. Here we’ll go over what you can expect your health insurance to provide.

As mentioned, different healthcare plans cover different things depending on your needs and your provider. But when you purchase a health plan through the Marketplace, you are guaranteed to receive the following 12 benefits:

  1. Ambulatory patient services — that is, outpatient care that you can get without being admitted into a hospital
  2. Emergency room services
  3. Hospitalization, including surgeries and overnight stays
  4. Birth control coverage
  5. Pregnancy, maternity, and infant care, both before and after birth
  6. Breastfeeding coverage
  7. Mental healthcare and substance abuse services, including behavioral treatment such as counseling and psychotherapy
  8. Prescription drugs
  9. Habilitative and rehabilitative devices and services, to help with injuries, disabilities, and chronic health conditions
  10. Laboratory services
  11. Wellness services, preventive care, and chronic disease management
  12. Pediatric services — these include oral and vision care for minors, however adult dental and vision coverage aren’t guaranteed

These benefits are the minimum requirement for Marketplace health plans, although specific services covered within each category can vary. Although the requirements are the same across all 50 states, certain states require insurers to provide additional benefits besides the ones listed. If you compare health plans in the Marketplace, you’ll be able to see the specific benefits offered by each one.

Health insurance plans can offer additional benefits besides the ones listed, such as dental and vision coverage. Medical management programs may also be provided, to help with specific needs like weight management, back pain, or diabetes.

It’s important to note that, if you require treatments for a condition that isn’t listed here, this is just a breakdown of what the majority of plans offer. When you go to compare plans, however, you choose to buy one, you’ll get more detailed information about what services are covered. You can also search for and browse health plans based on your specific needs, such as hospice services or a particular condition.

Preventive services are of particular interest when comparing plans on the Health Insurance Marketplace. Most of the plans offered are required to cover a set of preventive services at no cost, such as shots and screening tests. This is a wonderful benefit, especially for families, but you should note that services are only free when provided by a doctor in your plan’s network.

If you have a preexisting medical condition, you might naturally wonder if you’re at a disadvantage when shopping for health insurance. After all, you know that auto insurers are less likely to give good deals to people who’ve been in accidents before. You may wonder if having an existing condition might have a similar effect on risk-averse insurance providers.

The good news is, all Marketplace plans are guaranteed to cover treatments necessary for preexisting conditions. In fact, insurance plans are not allowed to reject you, charge you more, or refuse to provide coverage for any condition you might have had when your coverage started. Insurers are also not allowed to raise your rates based solely on your quality of health. Additionally, pregnancy care is covered from the day your health plan takes effect.

Getting coverage for dentists appointments deserves its own discussion altogether. That’s because health insurance plans don’t always cover dental treatments specifically. Dental insurance often works by its own set of rules, and you may have to buy a separate insurance plan for oral healthcare.

The Health Insurance Marketplace is open for enrollments 45 days per year, from November 1 to December 15. If you don’t have a good health insurance plan already, you should plan on signing up as soon as the window opens again. Of course, if you don’t like any of the plans offered in the Marketplace, private insurance is always an option as well. Just make sure you specifically ask about the services and benefits you need. Also ask about any coverage you may be at risk of needing, such as birth injuries if someone in your family is pregnant.

My Health Insurance Covers What? How to Find Out

As you’ve learned, health insurance plans can differ drastically from one another. Even if you purchased a plan through the Health Insurance Marketplace, in which case the above 12 benefits are guaranteed, there’s still much flexibility in what services are provided.

Before you go to the doctor or seek any other medical treatment that you need your insurance to cover, it’s important to make sure ahead of time that your plan will cover it. Unfortunately, figuring out if your health plan will cover a specific treatment isn’t always easy or obvious. It can often seem like health insurance is complicated, with more jargon than straightforward answers.

You also have to keep in mind that even when your health plan covers treatment, you will usually still have to pay part of the cost. This means that, in addition to finding out if your treatment is covered at all, you also need to find out how much you must be prepared to spend out of pocket.

In spite of the complications, with patience and the right steps, you can definitely verify whether a treatment is covered by your plan. The best place to begin is your insurance coverage paperwork. Your coverage documents are the legal contracts that describe exactly what services are covered in your health plan. You should have two of these documents: a short and simple summary, and a longer, more detailed coverage agreement. If you don’t have printed copies that you got when you signed up for insurance, you can still access them online. You can also request new copies and even ask for documents in a language other than English.

If you can’t find your coverage documents or can’t seem to make sense of them, there’s another convenient option: simply call your insurance provider’s customer service department. A service rep will be able to explain exactly what coverage you have in simple, plain language. They’ll also be able to answer any of your questions about specific services. When you call your insurance company, it’s important to take notes, including the date of the call and the name of the representative you spoke with. Besides helping you remember the information you needed on the call, having these details will be useful if you need to make a follow-up call later. You may even be able to speak with the same representative the next time you call.

Next, you’ll want to estimate the cost that you’ll be spending on medical care. The first thing you’ll need to know is what your deductible is for different services. Your deductible is the amount of money you have to pay before your insurance “kicks in,” covering the rest of the cost. For example, with a $1,000 deductible, you’ll have to pay the first $1,000 of treatment costs, and then your insurance will cover the rest. Of course, some services may not involve a deductible at all, but are simply covered altogether.

Another type of cost you may have to pay is the co-pay. This is a flat fee that you usually pay when you check-in for a medical appointment or at the emergency room. This is usually a small, manageable amount, but it’s still good to know what it is ahead of time.

Once you know your deductible or co-pay amount for the treatment you need, you will need to get an estimate of the treatment cost. This is something you will usually talk to your doctor’s office about. However, for particularly complex or costly procedures, such as surgeries, it may be hard to get an exact estimate. It’s important to spend plenty of time talking to both your doctor and your insurance company in cases like this, so you will go into it as informed and prepared as possible.

Hopefully this information has helped you answer the question, “health insurance covers what?” In addition to learning why having health insurance coverage is so important, you’ve also discovered what types of care are most often covered by health plans. And you now know how to make sure that your health insurance covers what care you need before you seek any treatment. The next time you need to know if your health insurance covers what you need, just remember what you’ve learned here.

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