What Does Health Insurance Cover?

Getting sick or injured probably isn’t on your “to-do list,” but stuff happens in life. That’s why having health insurance coverage for you and your family members is a great idea. 

Signing up for a health insurance plan can buy you security if you have unexpected medical costs that are too high to handle on your own. It also helps you cover the cost of essential health care to keep you healthy or to treat illnesses or injuries. 

Health insurance can also lower your out-of-pocket health care costs if you use network providers. And you can get access to preventive care services like vaccinations, screenings, and certain examinations at no cost. 

If don’t quite qualify for Medicare benefits yet, and you’re thinking about enrolling in a health insurance plan, it’s best to know what medical services and supplies your plan covers. While each health insurance plan differs, most plans offer the same basic benefits. Here’s a look at what you might be getting when you enroll in a health insurance policy.

What does health insurance cover?

Your actual coverage depends on your insurance provider and the plan you sign up for. Most plans on the market in the United States today offer, at minimum, the following essential health benefits:

1. Outpatient or ambulatory care services that you get in medical offices, clinics, day-surgery facilities, hospital outpatient facilities, and dialysis centers. This type of care includes services for:

• Diagnostics
• Treatment
• Intervention
• Observation
• Consultation
• Rehabilitation

2. Emergency care services 

3. Hospital inpatient care for surgeries or overnight stays.

4. Prenatal care

5. Maternity care 

6. Neonatal care 

7. Mental health care

8. Substance use disorder services such as:

• Counseling
• Psychotherapy

9. Prescription drug coverage 

10. Rehab services and medical equipment for rehab

11. Laboratory services

12. Preventive and wellness care services that can include the following:

• Certain vaccinations
• Screenings for conditions like high blood pressure, diabetes, high cholesterol, certain types of cancer, etc. 
• Counseling for smoking cessation or losing weight

13. Chronic disease management services

14. Pediatric care if you have children covered on your insurance policy

15. Birth control and breastfeeding benefits are also included in health insurance coverage but they are not considered essential care and are labeled as additional care. 

Many plans offer extra benefit packages such as:

• Dental care services
• Vision care
• Various management programs such as weight management, diabetes care, pain management, etc.

Depending on the plan, you may pay additional deductibles for extra benefits. You should discuss the details carefully with a plan representative before you sign up for any plan.

Do you have to use in-network providers to get coverage?

Not all insurance companies require that enrollees use network providers. However, if you enroll in a managed care plan, this means you must use the plan’s network of health care providers and suppliers in order to get coverage for services and supplies. 

Insurance companies use networks as a means of controlling and predicting more accurately the health care costs for beneficiaries. These lower costs are an advantage to the beneficiaries who get lower monthly premiums in return. 

Using network providers doesn’t work out for everyone. If you have your own primary care physician who isn’t in an insurance network, you may not want to switch to a different doctor. On the other hand, if you are new to an area, or don’t have regular health care providers, you may benefit from enrolling in a managed care plan. 

Before you sign up for a health insurance plan, it is important that you have all the details regarding your benefits and if you need to use in-network providers. You should take the time to ensure that you’re getting the coverage that meets your health care needs and your budget.