“Is this covered?” is one of the most common questions I get from members wondering about seeing a new doctor, changing medicines or trying a new treatment option. And I’m always happy when they call and ask me before using services because it helps them get a better sense of what to expect.
What does health insurance cover?
If a service is covered, it means your health plan will pay for some or all of the cost. Covered services typically include regular office visits with your doctor, tests, urgent and emergency care, hospital stays, prescription drugs, medical equipment and more. In most cases, your doctor also needs to be on the list of doctors that take your insurance – this list is also called the insurance network.
How much your health plan pays for depends on what type of care you use and where you get it. For example:
For example:
- Some covered services are completely free to you, like going to the doctor for preventive services. Your plan pays everything.
- For others – like seeing the doctor for a lingering sinus infection or filling a prescription for covered antibiotics – you’ll pay a fee. The amount you pay will be different depending on the type of plan you have, plus whether or not you’ve taken care of the amount you have to pay before your plan starts helping you (your deductible).
To get the biggest bang for your buck, use services your health plan covers (and go to providers in your network) whenever possible.
How do I know what’s covered by my health insurance?
Every plan – even plans through the same insurance company – covers different doctors, clinics, prescriptions and other services. This is often because there are different types of plans to choose from. For example, some members are surprised to learn that their plan covers things they didn’t expect, like their chiropractor visits and pumps for breastfeeding moms. I recommend checking that the care you want (and the location you want to go to) are covered before you make an appointment. If possible, it’s also a good idea to research the amount you might have to pay, too.
Here are five places to go for information:
- Your Summary of Benefits and Coverage (SBC) – Ask you insurance company for a copy of your plan’s Summary of Benefits and Coverage, sometimes called an SBC. This is a standard document that all plans are required to have. It lists the services the plan covers and how much; you can see a sample SBC here (PDF). If you’re a HealthPartners member, you can easily sign in to review your coverage.)
- Your plan’s cost estimation tools – Understanding health care costs can be complex, but some plans offer easy-to-use price transparency tools that can help estimate what you might pay out of pocket for a certain service at a certain location. These tools can be some of the best places to look to get an idea of not only what’s covered, but also how much you can expect to spend. Many HealthPartners members can sign in to access our cost estimate tools online.
- Your doctor search tool – Use your plan’s network, provider or doctor search tool. Different plans cover different doctors, specialists and clinics, so it’s important to make sure that the doctor you want to see is covered. If you’re a HealthPartners member, I recommend signing in to search your network – it’s the easiest (and fastest) way to find covered providers and locations.
- Your plan’s formulary (drug list) – If your plan includes prescription drug coverage, it’ll have a list of the medicines it covers, also known as a formulary or drug list. Review the list to make sure the prescriptions you need are included and if they need any special approvals (pre-authorizations). Some plans also offer a calculator tool to help you find the lowest prices on prescriptions from specific pharmacies or in different quantities; HealthPartners members can compare prescription costs online.
- Your Member Services team – There’s no such thing as a silly question. If you have any questions about what your plan covers, contact your insurance company. Member Services representatives are there to answer exactly these types of questions. They can tell you whether a doctor, prescription or service is covered, plus how much your insurance will pay. If you’re a HealthPartners member, you can see personalized contact options online – you can also call the number on the back of your member ID card.
You're reading the "Getting started with your plan" series
Have a health plan but not sure what to do next? This series can help you get started.
Part 1: How to get the most out of your health insurance
Part 2: How to figure out what your health insurance plan covers