What Does Health Insurance Cover?

Health insurance typically covers essential services, including annual check-ups, emergency care, hospitalizations, maternity care, mental health treatment, prescriptions, rehabilitation, lab tests, pediatric services and chronic disease management. Preventive services such as annual check-ups are usually covered at no out-of-pocket cost to the policyholder.

To find out what is covered under your plan, review the Summary of Benefits and Coverage, check for in-network providers and prescription coverage and understand how cost-sharing between you and your insurer works. Stay updated through your insurer or employer for any changes in coverage.

• What Your Health Insurance Covers
• Commonly Covered Services
• What Health Insurance Does Not Cover
• How to Find Out What Your Health Insurance Covers

Your health insurance typically includes a range of essential benefits, especially after the implementation of the Affordable Care Act (ACA). For individual and small group plans, particularly those offered through public exchanges like the federal Health Insurance Marketplace, ten core health benefits are mandated. These include preventive services, mental health care, prescription drug coverage and pediatric services.

It's important to note that while these essentials are standardized, specific coverage details may differ by state. Annual out-of-pocket limits — beyond which the insurer covers 100% of costs for essential benefits — vary by plan. There are no lifetime or annual maximum payment limits on these benefits.

Health insurance provides coverage for a range of essential health services designed to maintain or improve health and wellbeing. Most health insurance plans typically cover the following:

• 10 Essential Health Benefits
• Preventive Services
• Preventive Services for Adults
• Preventive Services for Women
• Preventive Services for Children
• Prescriptions
• Doctor Visits and Hospital Stays
• Pre-Existing Conditions

All plans available through federally facilitated health insurance marketplaces are required to offer 10 essential benefits, and most plans available for purchase directly from insurance companies cover these as well.

1. Regular check-ups, screenings and vaccinations for disease prevention and health maintenance.
2. Immediate medical attention for emergency conditions.
3. Hospital treatments, including surgeries and overnight stays.
4. Maternity and newborn care during and after pregnancy.
5. Behavioral health treatment for mental health and substance use disorders.
6. Prescribed medications covering various health needs.
7. Rehabilitation services, including physical and occupational therapy and necessary devices.
8. Laboratory services like blood and urine tests for diagnosis and monitoring.
9. Pediatric services ensure health coverage for children, including dental and vision care.
10. Management and care for chronic diseases, helping to maintain health over time.

Two other mandatory benefits include coverage for contraceptives and counseling, as well as breastfeeding support, which involves breast pump rental and lactation counseling.

The specific services covered within these broad benefit categories will differ according to your state's regulations, so always read the policy terms carefully.

All marketplace health plans, and many private health insurance plans cover preventive services without out-of-pocket like copayments or co-insurance, irrespective of whether the yearly deductible has been met. However, these services are free only when accessed through in-network providers.

Preventive service coverage is broken down into three categories:

Most health insurance plans cover preventive services for adults, including a diverse range of screenings, counseling and interventions. These services address specific health risks and needs across different age groups and risk factors, as detailed in the following table.

Preventive services for women range from reproductive health to cancer screenings and general wellness.

Preventive services for children cover a variety of health checks and interventions, vital for early detection, prevention and management of various health issues from birth through adolescence.

Prescription drug coverage is standard in most health insurance plans, but the specific medications covered can vary significantly between insurers. Each plan maintains its own formulary — a comprehensive list of approved medications. To understand which drugs are covered under your plan, you can access this formulary on the insurer's website by contacting them directly or through the documentation they provide.

Health insurance plans generally cover consultations with primary care physicians, specialists and various medical providers. This includes a broad range of services, from routine doctor visits to specialized care. Hospital-related expenses, including emergency services, surgeries, outpatient procedures and inpatient hospital stays, are also typically covered.

Consider staying within your plan's network, which usually means lower costs. You should also know about the cost-sharing structure of your plan, which includes deductibles, copayments and co-insurance. You are responsible for most costs until your plan's deductible is met, after which you will start paying co-insurance, which means you split the cost with the insurance company based on the structure of your plan.

Moreover, some plans may require referrals or prior authorization for certain services or specialist visits.

Thanks to the Affordable Care Act, health insurers cannot refuse coverage or charge additional premiums based on pre-existing conditions. This applies to all ACA-compliant plans, ensuring equal access to health insurance for individuals with any health history. This policy protects those with chronic or past medical issues from financial penalties related to their health conditions.

To find out what your health insurance covers, start by accessing the right resources and understanding key aspects of your plan so you can get a clear picture of your coverage. If you require further clarifications, contact the insurer.