What does my health insurance cover?

Whether you have health insurance provided by your employer, or you purchase it on your own, it can be hard to know what exactly is covered by your insurance. Will it cover your prescription pills? What about an annual check-up? Does it matter what doctor or provider you see?

The answer to these questions–and any other questions about what your health insurance covers–varies from plan to plan.

What are health insurance covered services?

Covered services are the services that are agreed upon between you and your health insurance company that will be covered by the health insurance package you purchase. For example, a health insurance policy can cover things like annual check-ups, prescription drugs and treatment services. Your health insurance provider agrees to cover the partial or full cost of these services as part of the package that you purchase.

How do I know what services are covered by my health insurance?

If you currently have an insurance plan, simply review your benefits to see which services are covered and which are not. Your plan may change, or it may have changed, if you sign up or have recently updated the policy you pay for.

If you purchase a health insurance policy through the Health Insurance Marketplace, your insurance will cover preventative services and essential health benefits as required by the Affordable Care Act. These 10 essential benefits include:

  • Outpatient care you receive without being admitted to a hospital
  • Emergency services
  • Hospitalization
  • Maternity and newborn care once your baby is born
  • Mental health and substance abuse services
  • Prescriptions
  • Rehabilitative and habilitative services
  • Lab services
  • Preventive and wellness services and chronic disease management
  • Pediatric services

What is a medical necessity versus covered service?

A medical necessity is not the same as a medical benefit. A medical necessity is something that your doctor has decided is a necessity to your health. A medical benefit is something that your insurance company has agreed to offer. There may be some cases where the treatment your doctor suggests may be a necessity, but it may not be covered by your insurance.

What do I do if the medical treatment I need is not covered by my health insurance?

In most cases, your doctor will do their best to be familiar with your insurance coverage and whether what he or she suggests is covered. However, there are so many insurance plans out there, there is no way your doctor can know everything about the plan of each patient. By understanding your insurance coverage, you can help your doctor recommend medical care that is covered in your plan. Here are a few tips to insure you understand your medical coverage:

  • Read your insurance policy.
  • If you have questions about your coverage, call your insurance company and ask.
  • Remember that your insurance company makes decisions about what will be paid for and what will not, it is not your doctor’s decision.

What happens if my doctor recommends care that isn’t covered by my insurance?

If you do choose to receive treatment that isn’t covered by your insurance plan, that is okay, it just means that you will have to pay for the treatment out-of-pocket. Beware that medical treatments, even the most simple, can be very costly, which is one of the biggest benefits of having medical insurance.

However, if your insurance company doesn’t allow you coverage for a specific treatment you have the choice to file a claim and challenge their decision. Before you decide to appeal, know your insurance company’s appeal process. This should be discussed in your plan handbook. Also, ask your doctor for their opinion, as he or she may be able to help you through the process.

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