What Does Health Insurance Cover? Your Guide

Health insurance is one of the most confusing aspects of being an adult. About a third of consumers don’t know what their deductibles are and about half didn’t know if COVID-19 treatments get covered.

Not understanding the basics of health insurance leads to huge medical bills and even bankruptcy. It’s your responsibility to know what medical coverage you have.

What does health insurance cover? Let’s demystify health insurance so you know what your medical plans cover.

Understanding the Basics of Health Insurance

Health insurance is an agreement between you and your insurance carrier. At its most basic level, you agree to pay the cost of insurance and the insurance carrier agrees to pay for certain treatments.

Within this agreement are terms that you might not understand that specify your medical coverage.

The premium is the amount you pay every year for health insurance coverage. This is usually paid in monthly installments.

The co-pay is the amount of money you pay out of pocket when visiting a doctor or specialist. Some plans have a co-pay for a primary physician visit of $10-$20, while a visit to a specialist is $20-$50.

Another important term to understand is the deductible. This is the amount that you pay out-of-pocket before insurance pays.

Here’s how that works. If you have a deductible of $5,000 and need surgery, you pay $5,000 to cover the deductible. Insurance will then pay according to your insurance contract.

Insurance might not cover the entire amount because you went to a facility outside of the insurance company’s network. You’ll end up paying a higher percentage for the procedure.

That’s the difference between in-network and out-of-network facilities. In-network care is covered by insurance, while out-of-network costs are a lot more.

It also depends on the co-insurance amount. Co-insurance is a percentage split between you and the insurance company once you meet the deductible. This is usually 70% paid by insurance and you pay 30%.

What Does Health Insurance Cover?

With so many terms and variables, how do you know what your insurance coverage is?

Insurance plans cover doctor’s visits, some preventative care (screenings, annual exams, and blood work), prescription medicine, and emergency care.

Check your policy to learn what your co-pay is. You may have one or some services are completely covered.

There are some things that health insurance plans have to cover, thanks to the Affordable Care Act. Medical plans purchased through the Healthcare Marketplace have to include 10 essential health care services.

Lab services, pediatric care, pregnancy and newborn care, emergency services, and preventative care get covered completely by insurance.

This includes screenings such as mammograms and pap smears.

If you have a child that needs pediatric care, know that dental and vision get covered under ACA health insurance plans. Adults do not get these additional services.

Health insurance plans don’t cover dental or vision care. These are separate policies that you have to purchase.

What isn’t covered by health insurance plans? Cosmetic procedures such as mole removals aren’t covered unless there is a medical reason for the procedure.

Experimental drugs and therapies aren’t covered by insurance companies. Fertility treatments aren’t covered by health insurance plans, either.

There are some things that get covered depending on your plan. Physical therapy, chiropractic care, acupuncture, and mental health services might not be covered by your policy.

Health Coverage and Premiums

Shopping for health insurance isn’t easy because there are so many things to consider. Most people get trapped into looking only at the monthly premium without thinking about the other aspects of medical coverage.

You can get a plan that has a low premium, but the deductible is very high. Should you need health care, you’ll have to pay thousands of dollars out of pocket before co-insurance begins.

On the other hand, there are plans that have a lot of covered services, but a higher premium.

Consider how often you make visits to the doctor, your budget, and if you need any other covered services.

How to Use Health Insurance

The first thing you need to do is read your plan. Understand what services your insurance company covers, the co-pays, and the deductible.

When it’s time to schedule an appointment with a health care provider, check with your health insurance carrier first. You want to find a provider that’s in-network. Most insurance companies have a search function on their websites to make it easier to find a provider.

You may need to get a referral from your primary care provider for certain services. Again, this depends on your specific plan.

If you were injured at work, you might need vocational rehabilitation services to resume earning an income again.

If you’re not sure, contact your health insurance company to find out if you can schedule an appointment on your own or need a referral.

What to Do if Your Claim Gets Denied

There are countless stories of people who received a medical bill for something that insurance should have covered. Claims get denied because of clerical errors or a misunderstanding.

If you have a medical claim that gets denied, it’s important to know what recourse you have. You can appeal the claim and have it reviewed again.

An external review is where an independent entity reviews the claim and they make the final call.

If the external review doesn’t work in your favor, you can file a complaint with your state’s insurance commission. That won’t be enough to reverse the decision, but it will put it on record that the insurance company didn’t provide coverage.

Understanding Health Insurance Coverage

What does health insurance cover? It depends on the agreement you have with your insurance company. You can’t assume that insurance companies cover all healthcare services.

You can assume that you’ll have a deductible to meet and a co-pay. Read and fully understand your health insurance plan before you buy it.

Now that you know more about health insurance, head over to the Family Health section of this site for tips to keep you and your family healthy.


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