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.
What does health insurance cover?
First, let’s talk about what we mean by “covered.” 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
Covered benefits often include:
- Regular doctor and specialist visits
Lab tests - Urgent and emergency care
- Hospital stays
- Physical therapy
- Prescription drugs
- 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:
Whether your health care provider is in network - The specific details of your plan
- What type of health care you get
Where you get your health care
To
How to check if your health insurance covers something
If you can, it’s a good habit to check your health insurance plan’s coverage first before you get care. These are some of the best ways to get answers:
Sign in to your plan’s online account
Most health insurance plans offer online account access to their members. One of the
For example, most HealthPartners members can
Use your plan’s cost estimator tools
Look for
Look at your plan’s Summary of Benefits and Coverage (SBC)
Most plans are required to have this handy document – look for something
Search your plan’s formulary (drug list)
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 (
Contact your plan’s Member Services team
Is it taking a while to find what you’re looking for? Don’t hesitate to get help from your plan’s member services representatives. You can get answers to simple questions, complex requests and much more. HealthPartners members can
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 share similar qualities when it comes to coverage. Knowing what type of plan you have 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.