Medical Benefits that are covered and not covered by Health Insurance Plans

The health insurance plan is an agreement between the insurance company and the policyholder. According to this agreement, the policyholder agrees to pay a fixed amount known as a premium to the insurance company who in return provides certain medical benefits such as coverage on medical tests, drugs, and medical treatment. However, the insurance company does not pay for all the medical services but agrees to cover the cost of certain covered benefits, listed in the policy document. Health plan usually covers most of the doctor and hospital visits, prescription drugs, wellness care, along with medical devices.

Besides, the covered services, health plan also lists the medical services that are not covered by the company. Policyholders are required to pay for any of the uncovered medical services that they receive. There are several types of health plans offered by different health insurance carriers. All these health plans do not have the same benefits that are covered by another plan. Therefore, the policyholders need to be aware of all the health benefits covered under their plans, so that they can avail of the benefits, if it is required.

Health Insurance Plans Usually Covers the Following Benefits

Health insurance plans available through a Health Insurance Marketplace are required to cover a set of preventive services at no cost to policyholders. Besides, preventive services, ACA-compliant health plans, and all private health insurance plans offered in federally facilitated marketplaces are also required to offer the following ten essential health benefits. Ten essential health benefits include:

  • Hospitalization in care of surgery or other medical treatment
  • Maternity and newborn care
  • Substance use disorder services and Mental health
  • Emergency services
  • Outpatient care that people get without being admitted to a hospital
  • Pediatric services
  • Laboratory services
  • Prescription drugs
  • Rehabilitative and habilitative services
  • Preventive and wellness services along with chronic-disease management
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Preventive Services

Preventive services are covered by some of the health plans, and these coverages may vary by state. Therefore, policyholders are required to review the preventive services that are covered by their plan. Preventive services help to detect disease or prevent illness or some other health problems. Some of the preventive services covered under the ACA-compliant health plans include:

  • One-time screening of abdominal aortic aneurysm
  • Screening of alcohol misuse
  • Prevention of cardiovascular disease with the use of Aspirin
  • Blood pressure & cholesterol screening
  • Colorectal cancer screening
  • Screening of depression
  • Diabetes-Type 2 screening
  • Diet counseling
  • Falls prevention for adults age 65 or older
  • Hepatitis B and C screening
  • HIV screening
  • Immunization
  • Screening of lung cancer
  • Obesity screening and counseling
  • HIV prevention and counseling
  • Statin preventive medication for adults age 40 to 75 who are at high risk
  • Syphilis screening
  • Tobacco use screening and cessation interventions
  • Tuberculosis screening for adults at high risk

Additional Benefits

Health insurance plans beside preventive healthcare services and essential health benefits may also include the following additional benefits such as:

  • Dental coverage
  • Vision coverage
  • Birth control coverage
  • Breastfeeding coverage
  • Medical management programs for specific needs like weight management, back pain, and diabetes.

Medical Services that are not Covered

As we all know that health insurance plans generally do not provide coverage for all medical services. Healthcare services that are usually covered by health plans are discussed above and now find about the medical services that are typically not covered by most of the health insurance plans.

Fertility Treatments

Fertility treatment costs are generally not covered by a health insurance plan. Perhaps health insurance companies are required to pay for the testing, which is carried out for the diagnosis of infertility. This is a treatment area that varies among states.

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Cosmetic Procedures

Medical services that are used to improve a person’s exterior appearance like plastic surgery and some dermatological procedures are usually not covered by typical health plans. Since many consumers opt for these procedures, they are offered with price transparency. For instance, a consumer looking for laser hair removal can call different providers to avail of price quotes from all healthcare providers.

Healthcare Products and Services of Latest Technology

Covering the cost of the latest technology-based healthcare products or services happens slowly, especially if the technology does not show added benefit for the increased costs. Healthcare companies are expected to provide a new drug, product, or test that offers a measurable benefit to the consumers, such that the added cost save lives or reduce ill-health. Health insurance plans usually follow suit and wait for additional data before including such services in the covered benefits.

Off-Label Prescriptions

Prescription drugs are first tested and approved to be used for the treatment of certain disorders like autoimmune diseases. However, at times these drugs can also be prescribed for health problems not listed on the label. In some of the cases, the insurance company may reject paying for off-label drugs.

Medical Necessity

Policyholders need to be aware that medical benefit and medical necessity is not the same. Medical benefits are medical services that health insurance plans agreed to cover, whereas medical necessity is medical service that the doctor has considered necessary for the policyholders. There might be cases when the doctor decides, that the person needs medical care that is not covered under his/her insurance plan. If a person is recommended a medical treatment, not covered by their insurance company, then they can obtain the treatment but they will have to pay for the treatment themselves. The insurance companies can deny such claims, though policyholders have the right to appeal against the decision. Before appealing, policyholders should be aware of their insurance company’s appeal process, as these are discussed in their plan’s handbook. Policyholders should also seek the advice of their doctors, and if their doctors think that it is right to appeal, then they should proceed, and doctors may also help them through the appealing process.

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