How to find out what your health insurance covers
Whether you’re waiting at the clinic to see a doctor, headed to the emergency room or scheduling an appointment online, the same question often comes up: Will this be covered?
Most health insurance plans help pay for a wide variety of services. But when it comes to knowing exactly what’s covered by your plan, it’s important to know where to look. That way, whether you’re seeing a doctor, having a procedure or just filling a prescription, you can quickly and confidently get the answers you need – and a sense of how much you might expect to pay.
When a health care service, medicine or item is covered, it means your health insurance plan will pay for some or all of the cost. Something that’s covered might also be referred to as a “benefit” or “covered benefit.” Generally, if you go to a provider in your plan’s network, your plan will help pay more costs. If you go to a provider outside your plan’s network, you’ll usually have to pay more (or even all) costs.
Covered benefits often include:
- Preventive care
- Regular doctor and specialist visits
- Lab tests
- Urgent and emergency care
- Hospital stays
- Physical therapy
- Mental health care
- Prescription drugs
- Vaccinations
- Medical equipment
- And more
However, different plans cover different services and items at different levels. Exactly what and how much your particular health insurance plan will pay for depends on:
- The specific details of your plan
- Whether your health care provider is in network
- What type of health care you get
- Where you get your health care
To get the most out of your health insurance coverage, it’s important to know how to look up what your plan covers.
Some services may not be covered by your health plan, or they may cost you more out of pocket. Common examples include:
- Dental care, which often requires separate coverage through a dental insurance plan
- Vision care, which often requires separate coverage through a vision insurance plan
- Elective and cosmetic procedures, such as treatments done to improve appearance rather than treat a medical condition
- Experimental or investigational treatments that haven't been approved for coverage by your health plan
- Non-traditional or alternative medicine, such as certain types of acupuncture, herbal remedies or massage therapy
- Services that need prior authorization but weren't approved before you received care
Keep in mind that coverage varies by plan. If you're not sure whether a service is covered, contact your plan's member services team. They can help you understand your benefits, costs and any steps you should take before getting care.
Whenever possible, it’s a good idea to check your health insurance plan’s coverage first before you get care. These are some of the best ways to get answers:
Most health insurance plans offer online account access to their members. You can quickly check which doctors are in network and see what your plan covers. Each benefit category usually has details about in-network and out-of-network benefits, coverage levels, out-of-pocket limits, prior authorization requirements, and more.
Look for cost estimator tools that can help you estimate your out-of-pocket costs for different services at different providers. These easy-to-use tools often take into account your specific plan’s coverage and network.
Most plans are required to have a handy document called a Summary of Benefits and Coverage (SBC). Look for something like this sample SBC (PDF). An SBC gives a general overview of what the plan covers, how much the plan pays and how much you’re responsible for.
Plans that include prescription drug coverage also have formularies (drug lists). These detail which medicines the plan will cover. Formularies also describe any special approvals (prior authorizations) you’ll need as part of your plan’s coverage. You can also find out what to do when your medication isn’t on the formulary.
Never hesitate to contact your plan’s member services representatives. You can make a quick phone call or send a message to get answers to questions like, “Is this doctor in my plan's network?” or “Do I need a referral to see a specialist?” or “Will this treatment be covered?”
Finding out what kind of health insurance you have (and why it matters)
Most health insurance plans can be categorized into different types. Plans that are the same type usually offer similar coverage. Knowing your plan type can help set your expectations of who may be in your network and what types of services are covered.
Common plan types include:
Preferred provider organization (PPO) plans – These plans include a specific network of doctors, clinicians and specialists. Most PPO plans cover care at bothin-network and out-of-network providers , but you’ll usually pay less out of pocket when going to in-network providers.Health maintenance organization (HMO) plans – HMO plans also have a specific network of providers, often local to the area you live or work in. But they usually limit coverage solely to care you get at those in-network providers. That means care you get at out-of-network providers typically won’t be covered, except for emergencies.
If you’re not sure what type of plan you have, talk to your employer or one of your plan’s member services representatives for more details.