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What Health Insurance Covers

Your health insurance policy is an agreement between you and your health insurance company. The health insurance plan lists a package of medical benefits like tests, drugs, and treatment services. The insurance carrier agrees to cover the cost of certain benefits listed in your plan. These are known as “covered services.”

Your policy also lists the types of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you obtain.

How to Know Services That are Covered

Your health insurance policy may not cover the same services that another plan covers.

If you already possess an insurance plan and want to keep it, review your benefits to see which services are covered. Your health insurance plan may not cover the same services that another policy covers. You should also compare your plan with those provided through the Health Insurance Marketplace. The Health Insurance Marketplace is a service that assists you to shop for and compare health insurance plans. The federal government operates it.

Essential Health Benefits

Many insurance policies will cover a set of preventive services. This doesn’t mean they are free. You may still need to pay deductibles, copayments, or other out-of-pocket expenses.

These preventive services comprise shots and certain health screenings. If you purchase a plan through the Health Insurance Marketplace, your insurance will cover the preventive services. It will also cover at least ten essential health benefits necessitated by the Affordable Care Act (ACA). All private health insurance plans provided in federally facilitated marketplaces will provide the following 10 essential health benefits (EHBs):

• Rehabilitative and habilitative services and devices (services and devices to help individuals with injuries, disabilities, or chronic conditions gain or recover mental and physical skills).
• Preventive and wellness services and chronic disease management.
• Prescription drugs.
• Pregnancy, maternity, and newborn care (care before and after your baby is born).
• Pediatric services, as well as oral and vision care (but adult dental and vision coverage aren’t EHBs).
• Mental health and substance use disorder services, as well as behavioral health treatment (this comprises counseling and psychotherapy).
• Laboratory services.
• Hospitalization (like surgery).
• Emergency services.
• Ambulatory patient services (outpatient care you get without being admitted to a health facility).

State-run marketplaces are also obligated to offer 10 EHBs, but the list of benefits may vary from those offered by federally facilitated marketplaces. Health insurance plans may offer additional coverage.

Preventive Services

Health insurance plans cover preventive services like tobacco use screening.

Preventive services can detect illness or help prevent illness or other health complications. The kinds of preventive services you need depend on your gender, age, medical history, and family history. All policies from the Health Insurance Marketplace must cover the following without charging a copayment:

For all adults:

• Tuberculosis screening for adults at increased risk.
• Tobacco consumption screening.
• Syphilis screening for those at increased risk.
• Statin preventive medication for adults 40-75 years at high risk.
• Sexually transmitted infection prevention counseling for those at increased risks.
• Obesity screening and counseling.
• Lung cancer screening for adults 55-80 years who are at increased risk for lung cancer due to smoking.
• Immunization vaccines.
• HIV screening.
• Hepatitis C screening for those at increased risk.
• Hepatitis B screening for those at high risk.
• Fall prevention for people of 65 years and over.
• Diet counseling for adults with the risk of chronic disease.
• Diabetes (Type 2) screening for adults 40-70 years who are overweight.
• Depression screening.
• Colorectal cancer screening for adults 50-75 years.
• Cholesterol screening for adults with higher risk.
• Blood pressure screening.
• Aspirin use for adults 50-59 years who would benefit from it.
• Alcohol misuse screening and counseling.
• Abdominal aortic aneurysm one-time screening (for men ages 66-75 who have smoked).

For expectant women or women who may become pregnant:

• Urinary tract or other infection screening.
• Syphilis screening.
• Rh incompatibility screening.
• Preeclampsia prevention and screening.
• Hepatitis B screening for pregnant women.
• Gonorrhea screening for all women at increased risk.
• Gestational diabetes screening.
• Folic acid supplements.
• Expanded tobacco intervention and counseling for expectant women who consume tobacco.
• Contraception.
• Breastfeeding comprehensive support and counseling.
• Anemia screening.

Preventive health services for children (and when they should be offered) relies heavily on age.

References and Resources

• 10 Essential Health Benefits
• Colorectal Cancer
• Rh Incompatibility