Your health insurance policy is an agreement between you and your insurance company. The policy contains a package of medical benefits, such as tests, medications, and treatment services. The insurance company agrees to cover the cost of certain benefits established in your policy. These are called “covered services.”
Your policy also establishes the types of services that are not covered by your insurance company. You must pay for any non-covered medical care you receive.
The 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 as another plan. You should also compare your plan with those offered through a Health Insurance Marketplace. The Health Insurance Marketplace is a service that helps you purchase 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 vaccinations and certain health tests. If you purchase a plan through a 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 federally facilitated markets will offer the following 10 essential health benefits:
- Outpatient 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 abuse disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitation and habilitation services and devices (services and devices to help people with injuries, disabilities or chronic conditions obtain or regain mental and physical abilities)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services
State-run markets will also need to offer the top 10 essential health benefits, but the list of benefits may differ from that offered by federally-provided markets. Plans may offer additional coverage.
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. Some preventive services covered by the ACA include blood pressure tests, cervical cancer screenings, HIV screenings, vaccinations, and follow-up visits for women. Coverage for preventive services also varies by state, so please review covered services carefully before choosing a plan.
What is a medical necessity? Is it 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 medical care that most patients need. Your insurance company’s decisions may mean that the test, drug, or service you need is not covered by your policy.
What should I do?
Your doctor will try to familiarize you with your insurance coverage so that we can provide covered care. However, there are so many different insurance plans that your doctor may not know the specifics of each plan. By understanding your insurance coverage, you can help your doctor recommend medical care that is covered by your plan.
- Take the time to read your insurance policy. It is best to know what your insurance company will pay before receiving a service, getting tested, or filling 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 it to you.
- Remember that your insurance company, not your doctor, makes decisions about what will and will not be paid.