Health Coverage in the U.S. – What is Covered?

Health coverage insurance is something you need to consider having if you don’t already have it. However, what is equally important is having the right information and knowledge about what sort of health coverage you will have with your insurance company. 

Your Health coverage insurance policy will agree to cover a package of different medical services, treatments, drugs, and other medical benefits such as tests. Upon an agreement between you and the insurance company, the list of benefits the company will pay on your behalf will be known as “covered medical services.”

Health insurance
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Knowing the type of services covered

If you have already applied for us health care insurance and plan to keep for the foreseeable future, it would do you well to review everything that the insurance covers thoroughly. However, there will be some services that may not be covered, which other insurance companies offer to cover. 

Before you buy insurance, spend some time comparing different plans, preferably via federal government websites. 

Private insurance companies offer these benefits 

A lot of insurance plans offer to pay for specific preventative services, which means you won’t have to pay for anything. These mainly include things like health screenings and shots. As per the ACA (Affordable Care Act), private insurance plans will get you the following coverage:

  • Outpatient care/ ambulatory services
  • Medical emergency services
  • Surgery/hospitalization
  • Prenatal care/maternity and newborn care (coverage will extend to care before and after the infant is born)
  • Health services for mental disorders/ substance use disorder (this also includes treatment for behavioral health, psychotherapy, and counseling)
  • Coverage for prescription drugs
  • Habilitative/ rehabilitative care and services (this also includes devices to help people who have sustained injuries, have disabilities or chronic conditions)
  • Laboratory services
  • Wellness services/ preventative medicine as well as chronic disease management
  • Pediatric services
Health insurance coverage
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The difference between medical necessity and a covered service

It is essential to understand that a covered service and a medical necessity are two different things. 

A medical necessity is something that your general physician or any other medical professional deems necessary for your wellbeing. Your insurance may not necessarily cover whatever treatment or medicine that is. 

On the other hand, a covered service is something that your insurance has agreed to pay for. This is why it is important to discuss your insurance with your doctor. 

The different types of health services, drugs, and tests that are to be covered is something that your insurance company will determine. The choices the company makes is in view and understanding of what type of medical services most patients need. 

This is what you can do

Although there are various types of health insurance plans, it is possible that your doctor or any other medical professional may know something about your insurance plan. So it is vital that you first discuss what your insurance primarily covers so that your doctor can recommend a treatment option that your plan covers. 

It is also essential to thoroughly read your insurance policy, even the fine print. It will be advantageous to know and understand what your potential health plan is going to pay for when you get treated, buy prescription medication, or get tested. Also, understand that it can be likely that specific types of tests or medical care will first have to be approved by your insurance company before your doctor can recommend them. 

Things you should consider in case your plan doesn’t cover what the doctor recommends

Your health insurance will most likely cover most of the things that your general physician recommends. However, there may be a lot of things that won’t be covered. So if you fill out a prescription or undergo a test that is not covered, you are going to have to pay for them. This is what is known as “a denied claim.”

But you can contest a denied claim as you have a legal right to appeal their decision. However, before you make an appeal, it is imperative to know about the process. If you don’t know your insurance company’s appeal process, you could easily be misled or act out of misinformation, which is going to work against you. 

You can learn about the appeals process by going through the handbook your insurance company is going to provide you. Most importantly, before you make an appeal, do consult your doctor and ask them if it is something that you should make an appeal for. They may be able to help simplify the appeals process. 

Health card
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The bottom line

It is a truism that understanding the complex working of private medical insurance is daunting. However, there is a vast amount of information posted by various companies on websites regarding how you can select a facility or a doctor, how you can review the drug formulation, etc. 

Use this information to select the right insurance plan. However, the best way to truly understand your coverage, it is better to have a face-to-face conversation with your insurance representative. 

Author Bio

Audrey Throne
Author: Audrey Throne

Audrey Throne has an ongoing affair with the words that capture readers’ attention. Her passion for writing dates back to her pre-blogging days. She loves to share her thoughts related to business, technology, health, and fashion. Find her on Twitter: @audrey_throne.


Featured Image by ar130405 from Pixabay

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