Insurance Plans – What is Covered

What is covered by insurance plans might seem like a simple question, but there isn’t an easy answer. Every plan is different, and the reasons might surprise you.

For individual plans or plans that you buy yourself, what is covered is determined by the group or company you buy it from. Most plans cover all of the basics with varying levels of deductibles and co-pays. Still, some plans cut corners to save money and may leave you uncovered (for example, a plan that excluded pregnancy or cancer coverage). Be sure to check the coverage before you purchase an individual plan.

For group plans that you get at work, especially with larger companies, what is covered is probably determined by your employer rather than the insurance company. In fact, many large companies are Self Insured and just contract with an insurance company to do the paperwork and negotiate fees.

What is Covered in the ACA

All private plans must cover a set of essential benefits as part of the Affordable Care Act.  Some insurance plans that you get from work may not cover all of these.  The benefits are:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (such as surgery)
  • Pregnancy, maternity, and newborn care (care before and after your baby is born)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

So suppose that you go to the doctor to get a tattoo removed, and the insurance company from your job at MegaCompany Inc. tells you that it won’t pay the bill because it’s not covered. The underlying reason is probably that MegaCompany decided not to cover tattoo removal.

It’s possible to buy insurance that covers everything, and the insurance companies would probably love to sell it, but the cost would be enormous.