What Does Health Insurance Cover?

Information about what a health insurance policy covers such as regular doctor visits for preventative care, hospital stays, surgeries, prescription medication, and much more.
What Does Health Insurance Cover?

Many preventative services are covered by the majority of insurance plans. They are not necessarily free. Deductibles, copayments, and additional out-of-pocket expenses can still be required.

Shots and certain health checks are among these preventive services. Your insurance will pay for the preventive services if you purchase a plan via the Health Insurance Marketplace. It will include at least 10 of the essential health benefits mandated by the Affordable Care Act (ACA). The ten essential health benefits listed below will be included in all private health insurance plans that are offered on the federal marketplace:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services (getting care from the closest hospital)
  • Hospitalization (such as surgery)
  • Pregnancy, maternity, and newborn care (after birth and during pregnancy care)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

Plans must also include the following benefits:

  • Birth control coverage
  • Breastfeeding coverage

Even if you haven't reached your deductible, plans must pay for these services when performed by an in-network provider without requiring a copayment or coinsurance.

What other things are covered?

All policies are different but most follow a standard summary of benefits showing the most common medical events. These services typically have a coinsurance attached to them. Listed below are the most common things covered.

Office visits

  • Primary care visits to treat an illness or injury
  • Specialist visit. These are doctors that specialize in a specific area. These include advanced studies such as Anesthesiology, Dermatology, Neurology, Oncology
  • Preventative care, screening, and immunizations.
  • Telehealth
  • Chiropractic care


  • X-ray
  • Blood work
  • Computerized Tomography (CT) scan
  • Magnetic Resonance Imaging (MRI)
  • Positron Emission Tomography (PET) scan

Prescription drugs

  • Generic
  • Preferred generic
  • Non-preferred brand
  • Non preferred generic
  • Specialty

Outpatient Surgery

  • Physician and surgeon fees
  • Facility fees

Immediate Medical Attention

  • Emergency room care
  • Emergency medical transportation - ambulance or by air
  • Urgent care, walk-in clinic

Staying in a Hospital

  • Facility fee (for example, a hospital room)
  • Physician fees
  • Surgeon fees
  • Long-term care

Mental Health or Substance Abuse

  • Outpatient services
  • Inpatient services

Pregnant Women

  • Office visits
  • Childbirth
  • Well baby visits and care
  • Prenatal and post-natal care

Recovery or Special Needs

  • Home health care
  • Rehabilitation services
  • Habilitation services
  • Skilled nursing center
  • Durable medical equipment
  • Hospice services

Other Services That May Be Included

  • Routine foot care
  • Hearing aids
  • Rehabilitative speech therapy
  • Physical therapy
  • Allergy testing
  • Chemotherapy
  • Diabetes education
  • Dialysis
  • Infusion therapy
  • nutrition al counseling
  • Prosthetic devices
  • Radiation
  • Reconstructive surgery
  • Transplants

As mentioned each plan is different and may include certain exclusions depending on the insurance company. These can include things like cosmetic surgery, acupuncture, dental, and vision for adults. Although plans typically cover the majority of health issues it is important to know what is excluded.

What happens if a doctor prescribes treatment that your insurance doesn't cover?

The majority of the recommendations made by your doctor will be accepted by your insurance, but some may not be. Your insurance provider won't pay the cost if you receive a test, treatment, or prescription that isn't covered. You can still get the treatments your doctor suggested, but you'll have to pay for them yourself. This is frequently referred to as "denying the claim."

You do have the right to appeal the decision if your insurance company rejects your claim. Learn about the appeals procedure with your insurance provider before you decide to appeal. Additionally, get the opinion of your doctor. Your doctor might be able to assist you in the appeal procedure if they believe it is appropriate to do so.

How to keep your medical cost down

The cost (premium) for health insurance is a reflection of medical care. The more it costs to take care of an individual, the more the insurer has to charge all their subscribers. To combat this, health insurance companies typically provide preventive care to their subscribers. Doing this helps individuals to stay healthy and doesn't cost the insurance companies a ton of money.

The main focus of preventive health is taking precautions to safeguard your health. It involves routines like regular doctor visits, Vaccinations, basic screenings, a good diet, exercise routine, and giving up smoking. By following these recommendations, you can either avoid significant health issues or detect them early on when they are easier to cure.

So how does an insurance company help you with preventative health? This is done by offering subscribers member perks or deals. This includes things like discount gym memberships, footwear, healthy eating, food delivery services, hearing aids, yoga, lasick, wearable fitness watches, vitamins, supplements, quit smoking programs… The list goes on and on. This encourages individuals to stay healthy and in return fewer visits to the doctor.

Take Advantage of Your Health Insurance. You should undoubtedly receive the maximum benefit from your health insurance plan since you are paying for it. The health insurance industry wants to keep you healthy now more than ever. Visit the website of your health insurance provider or give their customer service line a call to learn more about what they have to offer.

What costs are associated with health insurance plans?

When you have health insurance, you might assume that it will take the pressure off of finding affordable medical care. But that’s not always the case. Some plans are more affordable than others, and there are a number of costs associated with any type of health plan. These expenses include monthly premiums, deductibles, and other out-of-pocket costs that can add up quickly over time. Choosing the right plan can be crucial to saving you money.