Choosing the right health insurance plan is complicated. This blog explains how to tell which services are covered under your health plan. Understanding health plan coverage basics can help you choose an optimal plan.
Covered Vs. Non-Covered:
Not all medical services you receive are necessarily “covered” by your insurer. Some “alternative’ services such as massage therapy, yoga & acupuncture are not yet considered proven therapies & may not be covered by your insurer. This means you would have to pay for those services out of pocket and they will not go towards your deductible, coinsurance or reduce your out of pocket maximum.
This would be the same for out of network providers and specialists. If your plan does not have an out of network benefit, services received from out of network providers are also paid out of pocket and will not reduce your deductible, coinsurance or out of pocket maximum. These are instances of “non-covered” services. Your insurer typically outlines what types of services are considered “non-covered” in your Member Benefit Agreement outline.
If you are unclear how a specific medical service will be covered, it is best to contact your insurer directly. They will be able to advise whether services will be covered.
Covered Services:
- Emergency services
- Ambulatory patient services
- Hospitalization
- Maternity & newborn care
- Mental health & substance disorder services including behavioral health services
- Prescription medications approved by the FDA
- Rehabilitative & habilitative services & devices
- Laboratory services
- Preventive & wellness services
- Chronic disease management
- Pediatric services including vision and dental care
Services Typically Considered “Non-Covered”
- Holistic health doctors/uncertified “nutritionists”
- Treatments & medications that are not yet FDA approved
- Services that are not considered “Essential Health Benefits” such as vision/dental. Essential health benefits can vary from state to state as well as plan to plan
- Dental/vision services (some exceptions to this would be emergency dental due to accidental injury, impacted wisdom tooth extraction, glaucoma & cataract visits and care)
- Over-the-counter medications
- Commercial weight loss clinics (like Jenny Craig, Weightwatchers)
- Acupuncture – usually only covered if medically necessary & varies by insurer, always check your Member Benefit Agreement or contact your insurer directly
Preventative Care:
Typically, the following services are classified as preventive care, and one visit a year, or every 366 days (a year & a day), is covered 100%, no charge to the you, when received by an in-network provider:
- Annual physical/wellness visit
- Annual OB-GYN visits for women (they may also see their PCP for an annual physical)
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Colonoscopy = Colorectal Cancer Screening for adults ages 50-75
- Screening Mammogram at age 40 (any additional may come at a charge because they are classified as diagnostic; 3D mammogram may not be 100% covered)
- Diabetes type 2 screening for adults ages 40-70
- Hepatitis B & C screening
- Contraception & sterilization
- Various immunization vaccines for both children & adults
For a more comprehensive list of preventive services, visit: https://healthcare.gov/coverage/preventive-care-benefits/
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