What Does a Health Insurance Plan Cover?

Healthcare reform has improved and streamlined what all health insurance plans must cover. Most health insurance plans cover ten essential health benefits:

• Outpatient care (medical treatment received without being admitted to a hospital).
• Emergency services.
• Hospitalization (including surgery and overnight stays).
• Maternity, pregnancy, and newborn care.
• Mental and behavioral health care, including substance use disorder.
• Prescription drugs.
• Rehabilitative and habilitative services and devices (services and devices that help patients with injuries, disabilities, or chronic conditions gain or recover mental and physical skills).
• Lab services.
• Preventive care, wellness services, and chronic disease management.

For children, dental coverage is also included in coverage. On the Health Insurance Marketplace, adults have the option to purchase a dental plan in addition to their health plan.

While most health insurance plans cover those essential health benefits, each plan will have different amount of cost-sharing and out-of-pocket costs associated with accessing these health services.

Premium

The payment you make to a health insurance company or plan for your coverage. This is usually paid each month to keep your coverage.

Deductible

The amount you pay for health care services before your health plan begins to pay.

Copayment (Copay)

A set amount you pay for a medical service or supply. There may be different costs for a doctor’s visit, hospital outpatient visit, or prescription.

Coinsurance

A portion you pay as your share of the cost for services after you pay any deductibles.

Out-of-Pocket Maximum

The most you pay before your plan starts to pay 100% for covered services in a plan year.

Preventive Services

Routine health care screenings, check-ups, and vaccines. For example, flu shots, depression screenings, and blood pressure tests.

Understanding and Using Your Health Insurance

Learning about coverage can involve a lot of new information and unfamiliar terms, especially if you are new to health insurance. Fully understanding your health insurance is key to getting the most out of your coverage.

Here are few tips that will help:

• Understand your monthly premiums and out of pocket costs. Each month, you are required to pay your monthly insurance premium to stay enrolled in your health insurance plan. This is similar to how you pay for your your car insurance or home insurance. When you need to see a doctor, there will usually be an out-of-pocket cost that you must pay at your appointment, sometimes called a co-pay or co-insurance. Co-pays are in addition to the monthly premium you pay. Some insurance plans will require that you meet a deductible before they pay any amount toward your care.
• Know your health insurance network. Your provider network is a list of health care providers and hospitals that your health plan has contracted to provide medical care. A doctor or hospital who is included in your network is considered “in network” or a “network provider” and is always more affordable. Health care providers or facilities outside your network are “out of network” and are most costly.

These are just some of the basics. Another great resource for learning about using your coverage and improving your health is Coverage to Care: Roadmap to Better Care and a Healthier You document. We also have an online glossary of health insurance terms and a Frequently Asked Questions page about the Health Insurance Marketplace that may help you find the information you need.