What does health insurance cover?

What does health insurance cover?

Understanding Health Insurance Basics

Let's start by talking about the basics of health insurance. Health insurance is a contract between you and an insurance company, where you agree to pay a monthly premium, and in return, the insurance company helps cover the cost of your medical expenses. This can include doctor visits, hospital stays, prescription medications, and more. Health insurance is essential because it helps protect you and your family from the high costs of medical care, which can quickly add up without insurance.

Types of Health Insurance Plans

There are several types of health insurance plans available to suit your needs and budget. Some common types include:

  • HMO (Health Maintenance Organization) - Requires you to choose a primary care physician (PCP) and only covers care provided by doctors in the HMO network.
  • PPO (Preferred Provider Organization) - Allows you to choose any doctor, but you will pay less if you use doctors within the PPO network.
  • EPO (Exclusive Provider Organization) - Similar to an HMO, but you do not need a referral to see a specialist.
  • POS (Point of Service) - A hybrid between an HMO and PPO, you choose a primary care physician, but can also go out-of-network for a higher cost.

It's essential to understand the differences between these types of plans and choose one that best fits your needs and preferences.

What Health Insurance Typically Covers

Now that you have a basic understanding of health insurance and the types of plans available, let's dive into the specifics of what health insurance typically covers. Most health insurance plans will include coverage for the following services:

  • Preventive care - This includes annual check-ups, vaccinations, and screenings.
  • Emergency services - Health insurance covers visits to the emergency room and emergency medical transportation.
  • Hospitalization - If you need to be admitted to the hospital, your insurance will help cover the cost of your stay.
  • Maternity and newborn care - This includes prenatal care, delivery, and postpartum care for both mother and baby.
  • Mental health and substance use disorder services - Health insurance covers counseling, therapy, and treatment for mental health and substance use disorders.
  • Prescription medications - Most plans include coverage for prescription drugs, but the specifics may vary depending on the plan.

What Health Insurance May Not Cover

While health insurance covers a wide range of services, there are some things that it may not cover, such as:

  • Cosmetic procedures - Most insurance plans do not cover cosmetic surgeries or treatments unless they are deemed medically necessary.
  • Alternative therapies - Health insurance typically does not cover alternative treatments such as acupuncture, chiropractic care, or herbal remedies.
  • Infertility treatments - Some plans may cover fertility treatments, but it varies widely, so it's essential to review your plan's specifics.
  • Travel vaccinations - Health insurance usually does not cover vaccinations required for international travel.

It's crucial to carefully review your health insurance plan to understand what services and treatments may not be covered.

Understanding Deductibles, Copayments, and Coinsurance

When it comes to health insurance, there are three main terms you need to understand - deductibles, copayments, and coinsurance. These terms refer to the amount of money you are required to pay out-of-pocket for medical services before your insurance starts to cover the costs.

  • Deductible - This is the amount you must pay each year before your insurance begins to cover any costs. For example, if your deductible is $1,000, you must pay the first $1,000 of your medical expenses before your insurance starts to pay.
  • Copayment - This is a fixed amount you pay for specific services, such as a doctor's visit or prescription medication. Copayments are typically required after you've met your deductible.
  • Coinsurance - This is the percentage of the cost of medical services that you are responsible for after your deductible is met. For example, if your coinsurance is 20%, you will pay 20% of the cost of a medical service, and your insurance will cover the remaining 80%.

Out-of-Pocket Maximums and Annual Limits

Another important aspect of health insurance is the out-of-pocket maximum and annual limits. The out-of-pocket maximum is the most you will have to pay for covered medical expenses in a given year. Once you have reached this amount, your insurance will cover 100% of your medical expenses for the rest of the year. Annual limits refer to the maximum amount your insurance will pay for specific services in a year. For example, some plans may limit the number of physical therapy sessions they will cover in a year.

Pre-existing Conditions and Health Insurance

Under the Affordable Care Act (ACA), health insurance companies cannot refuse to cover you or charge you more due to a pre-existing condition. A pre-existing condition is a health problem you had before the start of your insurance plan. This means that even if you have a chronic illness or a previous health issue, you can still obtain health insurance and receive coverage for your medical needs.

How to Choose the Right Health Insurance Plan

When choosing a health insurance plan, it's essential to consider your needs and preferences. Some factors to consider include:

  • Monthly premium - This is the amount you will pay each month for your insurance. Make sure to choose a plan with a premium that fits your budget.
  • Deductible - Consider how much you can afford to pay out-of-pocket before your insurance kicks in. A higher deductible typically means a lower monthly premium, but it also means you'll have to pay more upfront for medical services.
  • Network - Make sure to choose a plan with a network that includes your preferred doctors and hospitals. If you want more flexibility in choosing doctors, consider a PPO or POS plan.
  • Covered services - Review the services covered by each plan and make sure they align with your needs. For example, if you have a specific prescription medication, make sure it is covered by the plan you choose.

How to Enroll in Health Insurance

There are several ways to enroll in health insurance, including through your employer, the federal or state marketplace, or directly through an insurance company. If you have access to employer-sponsored health insurance, this is often the most affordable option. If you do not have access to employer-sponsored insurance or prefer to purchase your own plan, you can explore your options through the federal or state marketplace during the open enrollment period. You can also contact insurance companies directly to inquire about their plans and pricing.


Understanding what health insurance covers and how it works is vital to ensuring that you and your family are protected from the high costs of medical care. Take the time to research different types of plans, consider your needs and preferences, and carefully review the specifics of each plan to make the best decision for your health and financial well-being.

Written by Loretta Smith

I am passionate about cooking and trying out new recipes, as well as exploring the food industry and health care. I believe that food is an important part of maintaining a healthy lifestyle, and I love to share my knowledge with others. I enjoy experimenting with different flavors and techniques to create unique and delicious dishes.