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What Does Insurance Cover

 “Does my insurance cover that?”

 “Does my insurance cover that?”

It’s a question I’ve heard asked many times, and it’s probably a question you’ve asked before. The healthcare landscape—especially insurance—can be a confusing mess. Trying to understand it is like untangling a mess of Christmas lights. You might get there eventually, but it’s not going to be easy and you will question your sanity at points.

I wrote this article to simplify things by answering: What do health insurance plans cover?

Essential Benefits Covered Under ACA

The Affordable Care Act (ACA), aka Obamacare, mandated all individual or employer sponsored health plans must cover these ten essential benefits without spending caps of any kind (annual or lifetime). Note: annual deductibles, copays, and out-of-pocket requirements must still be met, but once met, the medical expense cannot be limited.

Ambulatory patient services (outpatient care without being admitted to the hospital)

  1. Emergency services
  2. Hospitalization and hospital stays (such as surgery and overnight stays)
  3. Pregnancy, maternity, and newborn care (both before and after birth)
  4. Mental health and substance abuse disorder services
  5. Prescription drugs
  6. Rehabilitation and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
  7. Laboratory services
  8. Preventive and wellness services and chronic disease management
  9. Pediatric services, including oral and vision

In addition, a set of preventive services for men, women, and children are covered at 100 percent under the plans without charging copays, deductibles, or out-of-pocket costs. These include annual physicals, female contraceptives, and immunizations.

For a list of all fully covered services go to healthcare.gov. If you have coverage through your employer, ask for and review your employer’s Summary Plan Description (SPD).

Remember: The most efficient way to determine if your item is covered is to ask for the health insurance policy’s “not covered” or “exclusion” section.

What Does Minimum Coverage Cover?

Plans must cover the ten essential required benefits at an actuarial value of no less than 60 percent. Plans offered through healthcare.gov simplified the selection process by branding all plans that comply with the minimum actuarial value as bronze plans.

This is not to say that all healthcare insurance plans only cover the 60/40 percent split. There are 90/10 (platinum), 80/20 (gold), 70/30 (silver), and even some 50/50 (bronze as well) plans that comply with minimum actuarial value. Deductibles, copays, maximum out-of-pocket expenses and the amount you pay will vary by plan offering.

Note: What are medically necessary charges? Medicare’s definition of medically necessary charges is “health-related services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms, and that meet accepted standards of medicine.” In general terms, it excludes experimental unapproved procedures, and cosmetic procedures.

What Physicians and Hospitals Are Covered?

So far, we have highlighted what procedures are covered. You must also consider which providers are covered. Whatever plan or plans you are presented with and are considering, make sure they offer the doctors or hospitals or facilities that you use.

Different types of plans (HMO, PPO) and different insurance carriers (Blue Cross Blue Shield, Aetna, Cigna, United Healthcare, etc.) represent different providers. Some plans have more doctors and hospitals available and others fewer. Some are limited by area.

How do you find out if your providers are available? Ask for the provider directory. Each insurance carrier’s plan has its own unique list or directory. All are available online.

You are given the option to review the provider directories when you are applying for the insurance. Health insurance companies, employer plans, and government-sponsored plans offer multiple types of plans each with their own unique provider directory. When looking for your provider(s) in the carrier’s directory, make sure you are looking at the correct health plan. Different plans within the same carrier will have different lists of providers.

One Final Tip

If you don’t have a doctor relationship established, you need to ask how many doctors in the plan you are choosing are accepting new patients. Doctors on the list may not be taking new patients. Ask the insurance company or pick a doctor and call them to ask if they are taking new patients under the plan you are looking to select.

It’s a question I’ve heard asked many times, and it’s probably a question you’ve asked before. The healthcare landscape—especially insurance—can be a confusing mess. Trying to understand it is like untangling a mess of Christmas lights. You might get there eventually, but it’s not going to be easy and you will question your sanity at points.

I wrote this article to simplify things by answering: What do insurance plans cover?

Essential Benefits Covered Under ACA

The Affordable Care Act (ACA), aka Obamacare, mandated all individual or employer sponsored health plans must cover these ten essential benefits without spending caps of any kind (annual or lifetime). Note: annual deductibles, copays, and out-of-pocket requirements must still be met, but once met, the medical expense cannot be limited.

Ambulatory patient services (outpatient care without being admitted to the hospital)

  1. Emergency services
  2. Hospitalization (such as surgery and overnight stays)
  3. Pregnancy, maternity, and newborn care (both before and after birth)
  4. Mental health and substance abuse disorder services
  5. Prescription drugs
  6. Rehabilitation and habilitative services (those that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
  7. Laboratory services
  8. Preventive and wellness services and chronic disease management
  9. Pediatric services, including oral and vision

In addition, a set of preventive services for men, women, and children are covered at 100 percent under the plans without charging copays, deductibles, or out-of-pocket costs. These include annual physicals, female contraceptives, and immunizations.

For a list of all fully covered services go to healthcare.gov. If you have coverage through your employer, ask for and review your employer’s Summary Plan Description (SPD).

Remember: The most efficient way to determine if your item is covered is to ask for the health insurance policy’s “not covered” or “exclusion” section.

What Does Minimum Coverage Cover?

Plans must cover the ten essential required benefits at an actuarial value of no less than 60 percent. Plans offered through healthcare.gov simplified the selection process by branding all plans that comply with the minimum actuarial value as bronze plans.

This is not to say that all healthcare insurance plans only cover the 60/40 percent split. There are 90/10 (platinum), 80/20 (gold), 70/30 (silver), and even some 50/50 (bronze as well) plans that comply with minimum actuarial value. Deductibles, copays, and maximum out-of-pocket expenses will vary by plan offering.

Note: What are medically necessary charges? Medicare’s definition of medically necessary charges is “health-related services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms, and that meet accepted standards of medicine.” In general terms, it excludes experimental unapproved procedures, and cosmetic procedures.

What Physicians and Hospitals Are Covered?

So far, we have highlighted what procedures are covered. You must also consider which providers are covered. Whatever plan or plans you are presented with and are considering, make sure they offer the doctors or hospitals or facilities that you use.

Different types of plans (HMO, PPO) and different insurance carriers (Blue Cross Blue Shield, Aetna, Cigna, United Healthcare, etc.) represent different providers. Some plans have more doctors and hospitals available and others fewer. Some are limited by area.

How do you find out if your providers are available? Ask for the provider directory. Each insurance carrier’s plan has its own unique list or directory. All are available online.

You are given the option to review the provider directories when you are applying for the insurance. Health insurance carriers, employer plans, and government-sponsored plans offer multiple types of plans each with their own unique provider directory. When looking for your provider(s) in the carrier’s directory, make sure you are looking at the correct health plan. Different plans within the same carrier will have different lists of providers.

One Final Tip

If you don’t have a doctor relationship established, you need to ask how many doctors in the plan you are choosing are accepting new patients. Doctors on the list may not be taking new patients. Ask the insurance company or pick a doctor and call them to ask if they are taking new patients under the plan you are looking to select.

Let us know what you think!

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