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).
- Emergency services.
- 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).
- 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, 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.
- Depression screening.
- 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.
- HIV screening.
- Immunization vaccines.
- 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:
- Anemia screening.
- 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.
- Syphilis 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.
- Diabetes screening.
- Domestic and interpersonal violence screening and counseling.
- Gonorrhea screening.
- HIV screening and counseling.
- Osteoporosis screening for women over 60 years.
- Rh incompatibility screening follow-up testing.
- Sexually transmitted infections counseling.
- Syphilis screening.
- Tobacco use screening and interventions.
- Urinary incontinence screening.
- Well-woman visits for women under 65 years.
Preventive health services for children (and when they should be provided) depend heavily on age. To learn more about what services may be covered for your child, see a complete list appropriate for his or her age on healthcare.gov.
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
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:
Copayment: Sometimes this is called a “copay.” This is usually a set amount you pay for a visit, test, or medication. Copays are usually lower for family doctors than specialists.
Deductible: This is the amount of money you need to pay each year before the insurance company will cover all the remaining costs. It is often referred to as “meeting your deductible.” If you are healthy and don’t use healthcare often, having a high deductible and low monthly cost for insurance may make sense. However, if you become sick, then your costs may be higher.
Coinsurance: After you have met your deductible for the year, some insurance companies still require coinsurance. This is the percent of the cost that you will still pay for some services.
All of this can be confusing. It is important to know what your coverage plan offers before you sign. Call your insurance company if you don’t understand, or speak with your doctor for answers to your questions.
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?
Copyright © American Academy of Family Physicians
This information provides a general overview and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.