s Health Insurance Cover?" width="100%" height="145px" />Chris Kissell has been a journalist for three decades and has written extensively about insurance and other personal finance topics for the past 20 years. For the last 14 years, he has been a full-time freelance writer and editor, contributing to sit.
Chris Kissell Insurance WriterChris Kissell has been a journalist for three decades and has written extensively about insurance and other personal finance topics for the past 20 years. For the last 14 years, he has been a full-time freelance writer and editor, contributing to sit.
Written By Chris Kissell Insurance WriterChris Kissell has been a journalist for three decades and has written extensively about insurance and other personal finance topics for the past 20 years. For the last 14 years, he has been a full-time freelance writer and editor, contributing to sit.
Chris Kissell Insurance WriterChris Kissell has been a journalist for three decades and has written extensively about insurance and other personal finance topics for the past 20 years. For the last 14 years, he has been a full-time freelance writer and editor, contributing to sit.
Insurance Writer Les Masterson Deputy Editor, InsuranceLes Masterson is a deputy editor and insurance analyst at Forbes Advisor. He has been a journalist, reporter, editor and content creator for more than 25 years. He has covered insurance for a decade, including auto, home, life and health. Before cove.
Les Masterson Deputy Editor, InsuranceLes Masterson is a deputy editor and insurance analyst at Forbes Advisor. He has been a journalist, reporter, editor and content creator for more than 25 years. He has covered insurance for a decade, including auto, home, life and health. Before cove.
Les Masterson Deputy Editor, InsuranceLes Masterson is a deputy editor and insurance analyst at Forbes Advisor. He has been a journalist, reporter, editor and content creator for more than 25 years. He has covered insurance for a decade, including auto, home, life and health. Before cove.
Les Masterson Deputy Editor, InsuranceLes Masterson is a deputy editor and insurance analyst at Forbes Advisor. He has been a journalist, reporter, editor and content creator for more than 25 years. He has covered insurance for a decade, including auto, home, life and health. Before cove.
| Deputy Editor, Insurance
Updated: Feb 20, 2024, 7:02am
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Health insurance is something everybody needs. A good health insurance plan is the key to accessing the medical services you need at a price you can afford.
The more you understand about how health insurance works, the better equipped you are to find the best health insurance plan for your needs. Here is a breakdown of the most important aspects of a health insurance plan.
A health insurance policy covers many services, procedures and treatments. Here are a few examples of what health insurance typically covers.
Health insurance covers the cost of visits to see your primary physician, specialists and other medical providers. It also covers when you get health care services at a hospital, whether for emergency care or surgeries, outpatient care, procedures or overnight stays.
You might be responsible for the plan’s deductible, copayment and coinsurance costs. But as long as you remain in-network and your care is deemed medically necessary, the health insurance plan should pick up the lion’s share of the cost once you reach your plan’s deductible.
When the Affordable Care Act passed, it guaranteed that plans offered on the health insurance marketplace cover at least these 10 essential health benefits:
Health insurance plans also must cover birth control and breastfeeding services.
Health insurance plans must cover certain preventive health services at no cost to you. That means you can’t be charged a copay or coinsurance.
These services can be divided into three categories: all adults, women and children.
| Type of preventive services | People affected |
|---|---|
| One-time screening for abdominal aortic aneurysm | Men who smoke or smoked and reach a certain age |
| Alcohol misuse screening and counseling | No limit |
| Aspirin to prevent cardiovascular disease and colorectal cancer | People in their 50s with a high cardiovascular risk |
| Blood pressure screening | No limit |
| Cholesterol screening | People who are high risk or reach a certain age |
| Colorectal cancer screening Depression screening | Adults age 45 to 75 No limit |
| Diabetes (Type 2) screening | Adults age 40 to 70 who are overweight or obese |
| Diet counseling | People who are higher risk for chronic disease |
| Falls prevention (with exercise or physical therapy and vitamin D use) | Adults age 65 and over who live in a community setting |
| Hepatitis B screening | People at high risk |
| Hepatitis C screening | Adults age 18 to 79 |
| HIV screening | Adults age 15 to 65 and other ages at increased risk |
| PrEP (pre-exposure prophylaxis) HIV prevention medication | HIV-negative adults at high risk for getting HIV through sex or injection drug use |
| Immunizations, including chickenpox, measles, mumps, rubella, shingles and tetanus | Doses, recommended ages and recommended populations vary |
| Lung cancer screening | Adults age 50 to 80 at high risk for lung cancer, including heavy smokers or those who quit in the past 15 years |
| Obesity screening and counseling | No limit |
| Sexually transmitted infection (STI) prevention counseling | Adults at higher risk |
| Statin preventive medication | Adults age 40 to 75 at high risk |
| Syphilis screening | Adults at higher risk |
| Tobacco use screening | Adults and cessation interventions for tobacco users |
| Tuberculosis screening | Certain adults |
| Source: Healthcare.gov | |
| Type of preventive services | People affected |
|---|---|
| Breastfeeding support and counseling from trained providers and access to breastfeeding supplies | Pregnant and nursing women |
| Birth control | No limit, though requirement doesn’t apply to plans sponsored by exempt “religious employers” |
| Folic acid supplements | Women who may become pregnant |
| Gestational diabetes screening | Women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes |
| Gonorrhea screening | Women at higher risk |
| Hepatitis B screening | Pregnant women at their first prenatal visit |
| Maternal depression screening | Mothers at well-baby visits |
| Preeclampsia prevention and screening | Pregnant women with high blood pressure |
| Rh incompatibility screening | Pregnant women and follow-up testing for women at higher risk |
| Syphilis screening | No limit |
| Expanded tobacco intervention and counseling | Pregnant tobacco users |
| Urinary tract or other infection screening | No limit |
| Bone density screening | Women over age 65 or women age 64 and younger that have gone through menopause |
| Breast cancer genetic test counseling | Women at higher risk |
| Breast cancer mammography screenings | Every two years for women age 50 and older and as recommended by a provider for women age 40 to 49 or women at higher risk for breast cancer |
| Breast cancer chemoprevention counseling | Women at higher risk |
| Cervical cancer screening | No limit |
| Pap test (also called a Pap smear) | Women age 21 to 65 |
| Chlamydia infection screening | Younger women and other women at higher risk |
| Diabetes screening | Women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before |
| Gonorrhea screening | Women at higher risk |
| HIV screening and counseling | Age 15 to 65 and other ages at increased risk |
| PrEP (pre-exposure prophylaxis) HIV prevention medication | HIV-negative women at high risk for getting HIV through sex or injection drug use |
| Sexually transmitted infections counseling | Sexually active women |
| Tobacco use screening and interventions | No limit |
| Urinary incontinence screening | Women yearly |
| Well-woman visits to get recommended services | All women |
| Source: Healthcare.gov | |
| Type of preventive services | People affected |
|---|---|
| Alcohol, tobacco and drug use assessments | Adolescents |
| Autism screening | Children age 18 and 24 months |
| Behavioral assessments | All children |
| Bilirubin concentration | All children |
| Blood pressure screening | All children |
| Blood screening | Newborns |
| Depression screening | Adolescents beginning at age 12 |
| Developmental screening | Children under age 3 |
| Dyslipidemia screening | No limit |
| Fluoride supplements | Children without fluoride in their water source |
| Fluoride varnish | Infants and children as soon as teeth are present |
| Gonorrhea preventive medication for the eyes | Newborns |
| Hearing screening | Newborns and regular screenings for children and adolescents as recommended by their provider |
| Height, weight and body mass index (BMI) measurements | All children |
| Hematocrit or hemoglobin screening | All children |
| Hemoglobinopathies or sickle cell screening | Newborns |
| Hepatitis B screening | Adolescents at higher risk |
| HIV screening | Adolescents at higher risk |
| Hypothyroidism screening | Newborns |
| PrEP (pre-exposure prophylaxis) HIV prevention medication | HIV-negative adolescents at high risk for getting HIV through sex or injection drug use |
| Immunizations, including chickenpox (varicella), diphtheria, tetanus, inactivated poliovirus, influenza, measles, mumps, pneumococcal, rubella and rotavirus | Birth to age 18 |
| Lead screening | Children at risk of exposure |
| Obesity screening and counseling | No limit |
| Oral health risk assessment | Children between ages 6 months to 6 years |
| Phenylketonuria (PKU) screening | Newborns |
| Sexually transmitted infection (STI) prevention counseling and screening | Adolescents at higher risk |
| Tuberculin testing | Children at higher risk of tuberculosis |
| Vision screening | All children |
| Well-baby and well-child visits | No limit |
| Source: Healthcare.gov | |
Most health insurance plans are required to offer prescription drug coverage, but which medications are covered varies by insurer.
Your plan has its own formulary or list of approved medications. You can find this list on the health insurer’s website. This list also should be part of the documents your insurer provides to you. You can also call your insurer to find out which drugs are on the list.
In some cases, it might be possible to get an exception from your insurer to cover a medication not on its formulary. This is especially likely if none of the drugs on the formulary can treat your condition effectively. Contact your insurance company to learn more.
Health insurance companies that sold individual health insurance were once reluctant to cover care related to a pre-existing condition, which is a health issue that you already had before you looked for or actually purchased health insurance coverage. Insurers may decline coverage or charge exorbitant premiums.
That changed with the passage of the Affordable Care Act. Health insurers can no longer deny coverage or charge more due to diagnosis of a pre-existing condition.
Health insurance doesn’t cover everything. Here are examples of health care services that might not be covered.
Cosmetic procedures include things that reshape or enhance parts of the body, generally with a goal of improving appearance.
Health insurance doesn’t typically cover this type of care, although some plans might cover cosmetic procedures if deemed medically necessary.
Fertility treatments aren’t among the essential health benefits guaranteed by the federal government, and many insurers don’t offer coverage for such treatments.
But some states mandate that insurers cover at least some such services.
Many insurance companies will likely refuse to cover experimental or unapproved health care products and services that involve new technology.
Before using such new treatments, make sure your insurer is on board with covering the new approach.
An off-label prescription generally means the medication is being used in a way that the U.S. Food and Drug Administration hasn’t approved.
Your insurance company may or may not cover medications used this way, so it’s important to talk with your insurer to ensure such treatments will be covered.
Some health insurance plans may not cover products or services you need. Understanding your coverage as much as possible will help you avoid surprises.
It’s also possible that your health insurer may deny coverage for a claim after you already used a product or service. If this happens, and you believe you have coverage that applies, you have a right to request an internal appeal, in which the insurer will conduct a full and fair review of its decision.
If your claim still isn’t approved, you can request an external review, in which a third party will have the final say over the claim.
Health insurance companies use the term “medical necessity” to describe services that they cover. As a general rule, insurers will pay at least a portion of the cost for services that meet this definition. A service typically must be “medically necessary” before it will be covered.
A doctor’s willingness to say that a service is “medically necessary” may help convince an insurer that the service is necessary.
Understanding how your health insurance policy works is crucial to avoiding potentially costly mistakes. Here are some health insurance terms to understand:
Health insurers use the preapproval process to decide whether a medication, procedure or service is medically necessary.
That means you must get preapproval before pursuing these types of health care. If you do not, you may be responsible for the entire bill.
Physicians, hospitals and other medical providers who agree to accept your health insurance are known as “in-network” providers. All other entities are “out-of-network.”
Some insurance plans, such as health maintenance organization (HMO) and exclusive provider organization (EPO) plans, typically don’t cover out-of-network providers. That means you will be on the hook for all expenses incurred.
In other cases, the plan will pay for some of the charges, but usually at a much lower percentage than for “in-network” entities. That’s generally the case for preferred provider organization (PPO) and point of service (POS) plans.
Health insurance plans typically cover the cost of prescription drugs. That doesn’t mean they will cover all medications, so make sure you understand which drugs are covered and at what rate.
A copayment is a fixed amount that you might owe for seeing a provider or even for undergoing a lab test or getting a prescription medication. A copay to see a specialist or visit an emergency room is generally more expensive than going to your primary care provider or visiting an urgent care center.
A health insurance deductible is the amount you must pay out of pocket annually for health care services before your insurance kicks in. Deductible amounts can be high, often thousands of dollars.
Some insurance companies pay for specific services even before you meet your deductible. Check with your insurer to find out if it offers these services.
In addition, all plans sold on the marketplace must cover the full cost of some preventative benefits even before you meet your deductible.
Once you meet your deductible, your health insurer will pay a portion of the costs and you pick up the rest. That’s called coinsurance.
Coinsurance is the percentage of health care costs that you are responsible to pay once you reach your deductible.
For example, if your coinsurance is 20% and you are charged $100 for a health care service, you owe $20.
Health insurance comes with an out-of-pocket maximum that you can be charged each year. This amount is usually several thousand dollars. Once you reach your out-of-pocket maximum, you’re not responsible for health care costs for the rest of the year. The health plan pays all of the costs when you receive care.
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Insurance WriterChris Kissell has been a journalist for three decades and has written extensively about insurance and other personal finance topics for the past 20 years. For the last 14 years, he has been a full-time freelance writer and editor, contributing to sites such as Forbes, U.S. News and World Report, Money Talks News, Bankrate, GoBankingRates, FinanceBuzz and more. His work has also appeared on MSN, Fox Business and Yahoo Finance.
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