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 a Health Insurance Marketplace. Health Insurance Marketplace is a services 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 at no cost to you. This includes shots and certain health screenings. If you buy a plan through a 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)
  • Emergency services
  • Hospitalization (such as surgery)
  • 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)
  • Prescription drugs
  • 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)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services

State-run marketplaces will also be 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 illness or other health problems. The types of preventive services you need depend on your gender, age, medical history, and family history. Some preventive services covered under the ACA include blood pressure screening, cervical cancer screening, HIV screening, immunizations, and well-woman visits. Coverage for preventive services also varies by state, so review the services covered carefully before choosing a plan.

View a complete list of preventive services covered by insurance plans that meet ACA requirements.

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.

What should I do?

Your doctor will try to be familiar with your insurance coverage so he or she can provide you with covered care. However, there are so many different insurance plans that it’s not possible for your doctor to know the specific details of each plan. By understanding your insurance coverage, you can help your doctor recommend medical care that is covered in your plan.

  • Take the time to read your insurance policy. It’s better to know what your insurance company will pay for before you receive a service, get tested, or fill a prescription. Some kinds of care may have 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 it.
  • Remember that your insurance company, not your doctor, makes decisions about what will be paid for and what will not.

Things to consider

What happens if my doctor recommends care that isn’t 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 you get a prescription filled 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 obtain the treatment your doctor recommended, but you will 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, know your insurance company’s appeal process. This should be discussed in your plan handbook. Also, ask your doctor for his or her opinion. If your doctor thinks it’s right to make an appeal, he or she may be able to help you through the process.

Questions for your doctor

  • Are there certain types of insurance that you do not accept?
  • What type of coverage is most important for me and my family?
  • Are you in my insurance company’s network of providers?

Resources

Link to this page:

Preventive ServiceMenWomenChildren
Abdominal aortic aneurysm, one-time screeningAges 65 to 75 years who have ever smoked

 

Advice about aspirin use to prevent cardiovascular diseaseAges 45 to 79 yearsAges 55 to 79 years
Alcohol misuse screening and counseling
Anemia screeningPregnant
Autism screening

 

Ages 18 and 24 months
Behavioral assessments

 

Ages 0 to 11 months; 1 to 4 years; 5 to 10 years; 11 to 14 years; 15 to 17 years
Blood pressure screeningAll agesAll agesAges 0 to 11 months; 1 to 4 years; 5 to 10 years; 11 to 14 years; 15 to 17 years
Breast cancer genetic testing and counseling (BRCA)

 

Those who have higher risk for breast cancer
Breast cancer mammography screeningEvery 1 to 2 years after age 40 years
Breast cancer chemoprevention counseling Those who have high risk 
Breastfeeding – comprehensive support and counseling from trained providers; access to breastfeeding suppliesPregnant and nursing
Cervical cancer screening

 

Sexually active
Cervical dysplasia screeningSexually active
Chlamydia infection screening

 

Younger than age 25 and sexually active; older than age 25 with multiple sex partners
Cholesterol screeningAges 35 years and older; younger than age 35 and have heart disease or risk factors for heart diseaseThose who have heart disease or risk factors for heart disease
Colorectal cancer screeningOlder than age 50Older than age 50
Contraception – Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”Those who have reproductive capacity
Depression screeningAll agesAll agesAdolescents
Developmental screeningYounger than age 3
Diabetes (Type 2) screeningThose who have high blood pressureThose who have high blood pressure
Diet counselingThose who have higher risk for chronic diseaseThose who have higher risk for chronic disease
Domestic and interpersonal violence screening and counseling

 

All ages
Dyslipidemia screeningThose who have higher risk of lipid disorders at ages 1 to 4 years; 5 to 10 years; 11 to 14 years; 15 to 17 years
Fluoride chemoprevention supplementsThose without fluoride in their water source
Folic acid supplements

 

Those who may become pregnant
Gestational diabetes screening

 

For those 24 to 28 weeks’ pregnant and those at high risk of developing gestational diabetes
Gonorrhea screening

 

Those who have discharge from the penis or burning during urinationThose who have new or multiple sex partners; those not using a condom for each sexual encounter; those who use drugs; have ever had an STI
Gonorrhea preventive medicine (eyes)All newborns
Hearing screeningAll newborns
Height, weight, and body mass index measurementsAges 0 to 11 months; 1 to 4 years; 5 to 10 years; 11 to 14 years; 15 to 17 years
Hematocrit or hemoglobin screeningAll
Hemoglobinopathies or sickle cell screeningNewborns
Hepatitis B screening

 

People at increased riskPregnant at their first prenatal visitAdolescents at high risk
Hepatitis C screeningAdults at increased risk; one time for everyone born 1945-1965  
HIV screeningAges 15 to 65 years, and other ages at increased riskSexually active, ages 15 to 65 years, and other ages at increased riskAges 15 to 18 years and other ages at increased risk
Human papillomavirus (HPV) DNA screening

 

Every 3 years for those with normal cytology results who are age 30 years or older
Hypothyroidism screeningNewborns
Immunization

·       Diphtheria

·       Hepatitis A

·       Hepatitis B

·       Herpes Zoster

·       Human papillomavirus

·       Influenza (Flu shot)

·       Measles, mumps, rubella

·       Meningococcal

·       Pneumococcal

·       Rotavirus

·       Tetanus, diphtheria, pertussis

·       Varicella

 

Doses, recommended ages, and recommended populations varyDoses, recommended ages, and recommended populations varyDoses, recommended ages, and recommended populations vary
Iron supplements6 to 12 months at risk for anemia
Lead screeningThose at risk of exposure
Lung cancer screeningAges 55-80 at high risk because they’re heavy smokers or have quit in past 15 years  
Medical historyAges 0 to 11 months; 1 to 4 years; 5 to 10 years, 11 to 14 years ; 15 to 17 years
Obesity screening and counselingAll agesAll agesAll ages
Oral health risk assessmentAges 0 to 11 months; 1 to 4 years; 5 to 10 years
Osteoporosis screening

 

Older than age 60 depending on risk factors
Phenylketonuria (PKU) screeningNewborns
Rh incompatibility screening

 

Pregnant women and follow-up testing for women at higher risk
Sexually transmitted infection (STI) prevention counselingFor those at higher riskFor those sexually active and/or at higher riskAdolescents at higher risk
Syphilis screening

 

Those at higher riskPregnant or at increased risk
Tobacco use screening and interventions

 

All agesAll ages and expanded counseling for pregnant tobacco users
Tuberculin testingAt higher risk of tuberculosis at ages 0 to 11 months; 1 to 4 years; 5 to 10 years; 11 to 14 years, 15 to 17 years
Urinary tract or other infection screening

 

Pregnant
Vision screeningAll ages
Well-woman visitsYounger than age 65