After cost, the most important thing to almost anyone who has, or who is looking to get, health insurance, is coverage.
Specifically, most people want to know what their health plan does and doesn't cover when it comes to various treatments and services.
You'd think that would be easy enough to figure out, especially given its importance. Unfortunately, although a couple of documents--like a plan's Summary of Benefits and Coverage as well as its coverage agreement--provide at least some of that information, deciphering them can be difficult. (If you can't find your copies of these docs, by the way, check your insurer's website. And if that doesn't help, give them a call or send them an email.)
Although you'll need to track down one or both of those documents or talk with someone at your insurance company if you want specific details about your policy, keep reading to learn what the most common types of health plans generally do and don't cover.
Something to keep in mind here: just because one kind of health insurance tends to cover a particular treatment or service, that doesn't mean it covers it fully. Or it doesn't mean it covers it in all situations.
For example, all plans bought from the health insurance marketplace set up by the Affordable Care Act cover prescription drugs (as well as nine other "essential health benefits"). Don't assume this means the one you enroll in covers any medicines you have to take. It may not cover them at all, or it may only pay part of the cost after you've taken care of a deductible, copayment, or co-insurance.
With that out of the way, here are a number of typical services and treatments as well as how most job-based, Obamacare, and off-marketplace health plans cover--or fail to cover--them.
Doctor or Physician Visits
One of the main benefits of any type of health insurance is coverage of "ambulatory patient services." That's basically a fancy way of saying "care you get without being admitted to a hospital."
Doctor or physician visits are among the most common examples of ambulatory patient services. As such, it probably shouldn't be surprising to hear that pretty much every U.S. health plan in existence covers them.
Still, refer to your policy or call your insurance company before you schedule one of these visits. Many plans attach a copay or co-insurance to them, and you probably want to know how much that will set you back in advance of your appointment.
Blood Tests, X-rays, and More
These forms of outpatient care also are examples of ambulatory patient services. As are ultrasounds, other forms of imaging (like CT scans and MRIs), biopsies, colonoscopies, and more.
Again, most plans cover these services. This is true whether you get health insurance through an employer, the ACA marketplace, or directly from an insurance company. Some require copays or co-insurance, though, so check on the specifics of your policy before making an appointment.
Visits to Specialists
It's hard to imagine an employer, marketplace, or other health plan not covering visits to various kinds of specialists.
Still, some make you see specialists who are part of the plan's network. Others make you get a referral before they'll cover such visits. Or they make you pay extra if you go to an out-of-network specialist.
Reviewing your policy's benefits summary before you see a specialist can save you both time and money.
Chiropractors and Acupuncturists
The good news here is most kinds of health insurance are more likely to cover acupuncture and chiropractic care than they are to cover other sorts of complementary or alternative medicine. The bad news? You still may have a hard time getting that care covered.
Your best bet: get your doctor or physician to say the alternative care you need or want is medically necessary.
To learn more, read our "Guide to Alternative Medicine and Health Insurance."
Other Forms of Alternative Medicine
Do you or your doctor think aromatherapy or music therapy could help ease an ailment? Or maybe homeopathy or naturopathy might be the key?
You'll have a harder time finding a health plan that covers those forms of alternative medicine than you will finding one that covers acupuncture or chiropractic care. That's because insurance companies prefer to cover care backed by science.
Dental, Hearing, and Vision Care
When most of us think of dental, hearing, or vision coverage, we think of insurance that covers eye exams, glasses, hearing aids, or teeth cleanings. The health insurance you get from an employer or from the Obamacare marketplace usually won't cover those things. Some plans do, but many don't.
If you want that coverage and your job-based or marketplace plan doesn't provide it, you have to buy a separate policy. Before you do that, though, look through your plan's summary of benefits. Or contact your insurer and ask about it.
Regardless, keep in mind that most of these types of health insurance do cover dental, hearing, or vision care that's tied to a medical condition or issue.
Trips to the Emergency Room or Urgent Care
Thanks to the ACA (or Obamacare), health plans have to cover the ER visits of people experiencing an “emergency medical condition.” And they have to do this even if the hospital they go to is out of network.
Just remember: you're responsible your deductible and any copays or co-insurance even if you're "covered," so costs can still add up.
As a result, only go to the ER if you really think your situation is an emergency. If not, go to the nearest urgent care center. Most health plans cover those visits, too, and the associated out-of-pocket costs will be a lot easier on your wallet.
Outpatient and Inpatient Surgery
Remember those ambulatory patient services mentioned earlier (in the "Doctor and Physician Visits" section)? They usually include minor, outpatient surgical procedures--which means most health plans cover them.
Although they don't include more serious surgeries that require you to be admitted to a hospital, that's OK. The vast majority of health plans cover those procedures as well. The key here is for the surgery to be medically necessary. If your physician, specialist, or other care provider decides you need the surgery, your health insurance should pay for most or all of its costs.
That said, a lot of people, procedures, and costs are wrapped into even seemingly straightforward surgeries. To avoid being surprised by a bill after you get home from the hospital, talk with your doctor or surgeon beforehand. And contact your insurance company, too. Both will help you understand what portion of the final bill you'll have to pay out of pocket.
Shots, Screenings, Tests, and Other Preventive Care
No matter where you get your health insurance, it more than likely covers a wide range of preventive care. And not only that, but it likely covers that care without you having to deal with copays or co-insurance.
For more information on the kinds of check-ups, shots, screenings, and tests employer-sponsored, marketplace, and other health plans tend to cover in this area, read our article, "Health Insurance and Preventive Care."
Prescription Drugs
Most forms of health insurance help pay for prescription drugs, too. Part of the reason for that is the Affordable Care Act requires it of plans sold through the federal and state exchanges. It also requires it of plans offered by small employers. As for large employers, their plans usually cover prescription drugs because it helps them compete for talent.
Not all job-based, marketplace, or other health plans cover the same prescription drugs, however. Nor do they all cover them to the same extent. To learn more about this, and to learn more about how formularies or preferred drug lists fit into it, check out this article, "Will my health insurance cover substance abuse treatment?"
Physical or Occupational Therapy
Health insurance sold through the federal--or your state's--marketplace has to cover physical and occupational therapy thanks to Obamacare. The ACA also requires individual and "small group" plans (the latter are offered by small employers) sold off the marketplace to include this coverage.
Although the plans large companies and organizations offer to employees don't have to cover these types of therapy, most do.
Don't forget: just because a plan covers occupational or physical therapy, that doesn't mean it'll pay the full bill. As long as whatever you pay for treatment counts toward your deductible, it's "covered." And even if your plan picks up the entire tab, it likely puts a limit on how many times or how often it'll do so.
Want to know more? See this article of ours: "Does My Health Insurance Cover Physical Therapy?"
Mental Health Care
The majority of health insurance plans offered to Americans cover a broad range of mental health services, treatments, and drugs.
A few examples:
- Most health plans now cover certain preventive services--like depression screening--at no additional cost.
- All marketplace plans must cover behavioral health treatments like psychotherapy and counseling.
As for prescription drugs related to mental health care, insurance usually helps pay for them, too. To see which ones your plan covers, as well as how fully it covers them, check its formulary.
There's a lot more to how typical health plans do and don't cover mental health care. Educate yourself by reading this article, "What Kinds of Mental Health Care Does Health Insurance Cover?"
Infertility Treatment
If you get health insurance through the federal or state marketplaces set up by the ACA, it likely won't cover fertility drugs or infertility treatments. If you get it through an employer, especially a large one, you should have a lot more luck.
Even when health insurance does cover this kind of care, though, it often doesn't pay for its most expensive components. So, before you start or schedule anything, look at your policy's coverage summary. Or contact your insurer. And read our extensive article on the subject, "Health Insurance and Infertility Treatment Coverage."
Pregnancy and Childbirth
Once again, the Affordable Care Act comes to the rescue. Because of it, all plans offered on the health insurance marketplace must include maternity coverage. Plans sold outside the marketplace to individuals and small groups have to include this as well.
This coverage helps pay for a lot of vital services throughout a pregnancy, such as prenatal doctor visits, screenings, labor, delivery, newborn care, and more.
Most employer-sponsored health plans include this coverage, too, by the way. If you're not sure which aspects of a pregnancy or birth yours covers, talk with someone in human resources. Or contact the insurance company.
Weight-Loss Treatments
Losing weight isn't easy. It also isn't cheap--especially if your weight-loss plan includes surgery.
Despite that, many health plans now cover various kinds of weight-loss procedures, such as lap bands, gastric bypasses, gastric sleeves. This is true of marketplace as well as employer-sponsored plans.
Most also pick up the cost for obesity screening, nutritional counseling, and other related services.
Don't expect health insurance to pay for weight-loss medications or anti-obesity drugs, though. Few plans do these days, and for a variety of reasons. Learn why, and learn more about this kind of coverage in general, in this article: "Does My Health Insurance Cover Weight-Loss Treatments?"
Substance Abuse Treatment
Substance abuse is a serious problem both in the U.S. and around the world. That probably explains why many job-based and marketplace health plans, as well as those bought directly from insurance companies, cover at least some of the treatments associated with it.
Unfortunately, because health plans differ so much in this area, it's hard to say if a particular one covers long-term inpatient care, outpatient care (through 12-step groups), counseling, or maintenance medications. Reviewing a policy's benefits summary should help you figure that out. If not, contact the insurer and ask about it.
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