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Health Insurance Coverage: What Is and Isn't Covered?

If you're shopping for health insurance coverage, you should know that every plan is different. Some plans cover the majority of care while others limit your health insurance coverage to major medical benefits. It's important to know exactly what is and isn't covered, so there won't be any surprises down the road.

How Health Insurance Coverage Works

Health insurance coverage is the package of services that an insurance company has agreed to pay. To understand what may or may not be covered, it's helpful to look at a few basics.

  • Your doctor may decide you need certain tests, treatments or procedures out of medical necessity.
  • A medical benefit is something your plan has agreed to cover, either partially or fully.

Health Insurance Coverage Limits

Knowing your health insurance coverage limits ahead of time is important. Some expenses may not be covered, and some may only be partially covered. Just a few of these limits may include:

  • Care that you receive outside your plan's network
  • Plan restrictions for certain types of care
  • Over-the-counter drugs
  • Alternative therapies, such as massage and acupuncture
  • Behavioral health therapy
  • Cosmetic surgery

There are plans available that may cover some of these types of expenses. Some plans offer at least partial health insurance coverage for treatment from doctors and hospitals outside their network. On the other hand, over-the-counter drugs are rarely covered. So it's a good idea to look at a plan carefully to see what is fully, partially, or not covered at all. Then you can plan for and budget your out-of-pocket expenses.

The Right Balance of Health Insurance Coverage

Balancing what you can afford and the health insurance coverage you need is the key to finding the right plan. Here are a few tips for finding the right plan.

  • It's best to choose a plan that covers services you'll use frequently — even if it means a higher premium — because it will save you money in the long run.
  • For greater cost savings, select a doctor within the plan's network.
  • Take the time to read the details about the plans you are considering — ask for the Outline of Coverage.
  • If you have any questions about your health insurance coverage, contact a customer service representative.

Be proactive and learn about the coverage of plans that you are considering. It will help ensure the best health care for you and the ones you love.

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