What does health insurance cover?
Health insurance typically covers a variety of services, including doctor visits, emergency room visits, hospital stays, lab work, and preventive care. Health insurance plans do not cover a few things, including cosmetic surgeries, alternative medicine, infertility or experimental treatments.
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Brandon Frady
Licensed Insurance Agent
Brandon Frady has been a licensed insurance agent and insurance office manager since 2018. He has experience in ventures from retail to finance, working positions from cashier to management, but it wasn’t until Brandon started working in the insurance industry that he truly felt at home in his career. In his day-to-day interactions, he aims to live out his business philosophy in how he treats hi...
Licensed Insurance Agent
UPDATED: Oct 12, 2024
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UPDATED: Oct 12, 2024
It’s all about you. We want to help you make the right coverage choices.
Advertiser Disclosure: We strive to help you make confident insurance decisions. Comparison shopping should be easy. We are not affiliated with any one insurance company and cannot guarantee quotes from any single insurance company.
Our insurance industry partnerships don’t influence our content. Our opinions are our own. To compare quotes from many different insurance companies please enter your ZIP code above to use the free quote tool. The more quotes you compare, the more chances to save.
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Getting health insurance is a great way to safeguard your finances and well-being in the event of an unexpected illness or injury.
So what does health insurance cover? Health insurance generally covers hospital and inpatient services, preventive care, doctor visits, and prescription drugs. It may also cover certain specialist services, such as physical therapy or mental health counseling.
But health insurance does not always cover everything. Read on to learn more about what your insurance covers and does not cover whether you have individual health insurance or an employer-provided plan.
- Health insurance plans usually cover a range of services, including preventative care, doctor visits, and inpatient hospitalization
- Health insurance plans do not typically cover cosmetic surgeries, alternative medicine, or experimental treatments
- If your plan does not cover a procedure or treatment, other options may be available to you
What It Means to Be “Covered”
What is covered by health insurance and what does it mean to be covered? Regarding health insurance, being “covered” means that your insurer will pay for a portion of the services you receive. Your deductible and copays typically determine this portion. In addition, your doctor has to be within your insurance network for your insurer to cover the services.
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What does health insurance cover?
What does health insurance do for you? Health insurance coverage can be a confusing topic. It’s good to understand what services, procedures, and treatments are covered by your health insurance policy to make the most of it.
Here is a comprehensive list of the services, procedures, and treatments usually covered by health insurance plans.
Doctor Visits & Inpatient Services
A health insurance policy will typically cover the cost of doctor visits and inpatient services. These include hospital stays, emergency room visits, and visits to specialists, such as pediatricians, obstetricians/gynecologists, psychiatrists, and more.
While you may still have some out-of-pocket expenses like copayment, coinsurance, and deductible costs, your insurance will typically pay most of your medical bills as long as they are deemed medically necessary. The care provided should also be within your network of providers.
Preventative Care
Health insurance covers preventive care to help keep you healthy. It is available at no cost and includes services like checkups, screenings, and vaccines. There are three categories of preventative care: all adults, women, and children.
For all adults, services include:
- Abdominal aortic aneurysm
- Alcohol misuse screening and counseling
- Blood pressure screening
- Cholesterol screening
- Colorectal cancer screening (adults 45 to 75)
- Depression screening
- Diabetes (Type 2) screening (overweight or obese adults 40 to 70 years)
- Diet counseling
- Hepatitis B & C screening
- HIV screening
- HIV prevention medication
- Immunizations
- Sexually transmitted infection (STI) prevention counseling
- Tuberculosis screening
For women, services include:
- Screenings for breast and cervical cancer
- Well-woman visits
- Contraceptive counseling and supplies
- HIV prevention medication
- STI and urinary tract infection screening
- Gestational diabetes screening
- Birth control
- Folic acid (for women who may become pregnant)
- Rh incompatibility screening
For children, services include:
- Infant and child immunizations
- Autism screening
- Sickle cell anemia screening
- Obesity screenings and counseling
- Hearing, vision, and dental screenings
- Lead poisoning screening
- Developmental assessments
- Hypothyroidism screening
This is just a sample of the preventive care services covered by insurance. It is important to know what your plan covers, as this will vary from plan to plan.
Essential Health Benefits
In addition to the services listed above, all health insurance plans must cover these ten essential health benefits (EHBs).
- Ambulatory patient services
- Emergency services
- Hospitalization
- Laboratory services
- Maternity and newborn care
- Mental health and substance use disorder services
- Prescription drugs
- Preventive and wellness services
- Pediatric services, including oral and vision care
- Rehabilitative and habilitative services and devices
It’s worth noting that these 10 benefits of health insurance don’t cover dental and vision care for adults. However, they may be added as additional riders or benefits.
Pre-existing Conditions
Another component of health insurance is coverage for pre-existing conditions. Under the Affordable Care Act, this includes any medical condition that existed before enrolling in the plan. This means that all health insurance plans must cover these pre-existing conditions.
No one can be denied coverage or charged a higher premium due to an existing medical condition. Read more about health insurance plans for people with pre-existing conditions.
Prescription Drugs
Prescription drugs are a crucial component of health insurance coverage. Most plans will cover a range of prescription drugs, although the detailed list of covered medications may vary from plan to plan.
Contact your health insurance provider to get a list of covered medications and information about formulary tiers and copays.
What does health insurance not cover?
While health insurance usually covers many medical services, it does not cover a few things. These include:
Cosmetic Surgery
Cosmetic surgery is any surgery done to improve appearance rather than treat any underlying medical condition. This includes facelifts, liposuction, Botox injections, and breast augmentation. This type of surgery is generally not covered by health insurance.
Unless these procedures are deemed medically necessary due to an underlying medical condition or injury — such as reconstructive surgery after an accident — you will be responsible for the full cost out-of-pocket.
Experimental Treatments & Medications
Health insurers do not usually cover experimental treatments and medications because they have not been approved by the FDA yet as safe and effective treatments for a specific condition or disease.
In some cases, insurers will cover experimental treatments if a doctor has recommended them as a potential solution to a particular health issue.
However, checking with your insurer before undergoing any experimental treatment or medication is best to ensure it is covered under your policy.
Uncovered Prescription Drugs
Some prescription drugs, particularly those not deemed medically necessary for treating a specific condition, are not covered by health insurance.
Some insurers, for example, do not cover drugs used to treat non-life threatening conditions such as hair loss or erectile dysfunction.
Infertility Treatments
Infertility treatments are not usually covered by health insurance, as they are considered elective procedures. These include treatments like in-vitro fertilization (IVF) and intrauterine insemination (IUI).
However, some states, including Massachusetts and New York, have laws that require insurers to cover fertility treatments, so check with your state’s insurance commissioner to find out if you are eligible.
Alternative Treatments
Health insurance plans don’t always cover alternative treatments like acupuncture and chiropractic care.
Generally, these treatments must be medically necessary or prescribed by a physician to be eligible for coverage.
Additionally, some health insurers will only cover a certain percentage of the cost or up to a specific dollar amount per session.
Weight Loss Programs
Many health insurance plans do not cover weight loss programs like diet and exercise or bariatric surgery. Most health insurance plans also don’t cover gym memberships or personal trainer costs.
What if my insurance doesn’t cover a procedure that I need?
It can be frustrating when you need medical attention, and your insurance won’t cover it. So what are some reasons why your insurance might not cover a particular procedure or service, and what can you do to get the treatment you need? Let’s take a look.
Medical Necessity Denial
Sometimes, a procedure or treatment is not covered because the insurer determines that it is not medically necessary for your particular situation.
If this happens to you, you can appeal the decision by submitting a letter of medical necessity to your insurer. The letter should include information about why you need the procedure or treatment and why it is a medically necessary part of your treatment plan.
Incorrect Referral or Prior Authorization
Health insurance plans may also deny coverage if you did not receive a referral or obtain prior authorization from your primary care doctor before receiving the service.
For example, if you receive a referral for a specialist but do not obtain prior authorization from your primary care doctor, the insurer may deny coverage for the services.
In this case, you should contact your primary care doctor and ask them to submit a referral or prior authorization request on your behalf.
You Received Care From an Out-of-Network Provider
Your insurer may not cover the services if you receive care from an out-of-network provider. Health maintenance organizations (HMOs) and exclusive provider organizations (EPOs) usually only pay for care from doctors and hospitals in their networks.
If you find yourself in this situation, you can ask the provider if they will accept your health plan’s in-network rate.
Many providers may be willing to do so if you provide proof of insurance. But if not, you will have to look for an in-network provider or pay out of pocket for the services.
Other Mix Ups or Errors
Sometimes, a claim can be denied due to an administrative error. For example, incorrectly entered information on claims forms when submitting them for payment — or other mix-ups with enrollment information between employers and insurers confusing who should pay for certain services or medications prescribed by doctors (this happens more often than people realize).
If this happens to you, it is important to contact your insurer promptly and provide documentation that shows the error.
If the mistake is corrected quickly, you may be able to get coverage for the procedure or treatment.
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Other Costs Associated with Health Insurance
In addition to the treatments and services covered by health insurance, you may also be responsible for certain out-of-pocket costs. These can include:
- Copayments: These are the fixed fees you pay for certain services or medications.
- Deductibles: These are the annual amounts that you must pay out of pocket before your insurance starts paying for services.
- Coinsurance: This is the percentage of medical expenses you must pay after you reach your deductible.
Before signing up for a health insurance plan, read the terms and conditions carefully and become familiar with any out-of-pocket costs you may be responsible for to avoid surprises. Find out the best comprehensive healthcare providers.
Questions You Should Ask Your Doctor About Health Insurance Coverage
Before receiving any treatment or services, talk to your doctor about what your health plan covers and any additional costs you may be responsible for. Here are some questions you should ask them:
- Are you in-network with my health plan?
- Is the treatment I need covered by my plan?
- What type of insurance do you not take?
- Do I need a referral or prior authorization for this service?
These questions can help you avoid any unexpected costs or potential coverage denials.
What does medical insurance cover: Final Thoughts
The importance of asking “what does insurance cover?” and understanding what is covered by your health insurance plan cannot be understated.
Knowing the right questions to ask and doing your due diligence upfront can help take a lot of the guesswork out of deciding what services are covered and which ones aren’t.
It’s also important to understand what it means to be “covered” by health insurance and learn about the benefits of having the right plan.
It’s essential to determine if your plan covers a procedure or treatment you need before considering it. Many insurance companies have lists of in-network providers and treatment facilities that offer cost savings for their customers when receiving care.
Always ask questions about what is covered before committing to any healthcare service. This way, you can avoid unnecessary financial concerns and get the help you need most.
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Frequently Asked Questions
What does health insurance cover?
Health insurance typically covers medical expenses such as doctor visits, hospital stays, surgery, prescription drugs, and some preventive care services. The coverage and limits of a health insurance plan vary based on the plan type and the insurance provider.
Does health insurance cover pre-existing conditions?
Yes, under the Affordable Care Act (ACA), health insurance providers are required to cover pre-existing conditions. However, some insurance plans may have waiting periods before covering certain pre-existing conditions.
What preventive care services are covered by health insurance?
Preventive care services that may be covered by health insurance include annual check-ups, cancer screenings, vaccinations, and certain lab tests. However, coverage may vary based on the specific plan and insurance provider.
Does health insurance cover mental health services?
Yes, under the Mental Health Parity and Addiction Equity Act of 2008, health insurance providers are required to cover mental health services, including therapy and counseling.
Will health insurance cover alternative medicine treatments?
It depends on the specific plan and insurance provider. Some health insurance plans may cover certain alternative medicine treatments, such as acupuncture or chiropractic services, while others may not.
Does health insurance cover dental and vision care?
It depends on the specific plan and insurance provider. Some health insurance plans may include dental and vision coverage, while others may require separate policies for these types of services.
Are prescription drugs covered by health insurance?
Yes, most health insurance plans cover prescription drugs, but the specific drugs covered may vary based on the plan’s formulary. Additionally, some plans may require a co-pay or coinsurance for prescription drugs.
Does health insurance cover emergency medical care?
Yes, most health insurance plans cover emergency medical care, including ambulance services and emergency room visits. However, coverage may vary based on the plan and insurance provider.
Are pre-existing conditions covered by health insurance?
Yes, under the Affordable Care Act (ACA), health insurance providers are required to cover pre-existing conditions. However, some insurance plans may have waiting periods before covering certain pre-existing conditions.
Does health insurance cover international medical care?
It depends on the specific plan and insurance provider. Some health insurance plans may offer coverage for international medical care, while others may not. It is important to check with your insurance provider before traveling abroad.
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Brandon Frady
Licensed Insurance Agent
Brandon Frady has been a licensed insurance agent and insurance office manager since 2018. He has experience in ventures from retail to finance, working positions from cashier to management, but it wasn’t until Brandon started working in the insurance industry that he truly felt at home in his career. In his day-to-day interactions, he aims to live out his business philosophy in how he treats hi...
Licensed Insurance Agent
Editorial Guidelines: We are a free online resource for anyone interested in learning more about insurance. Our goal is to be an objective, third-party resource for everything insurance related. We update our site regularly, and all content is reviewed by insurance experts.