The high costs of most medical treatments, procedures, and prescriptions make health insurance a must have in today’s world. Insurance can help cover expensive medical-related costs and simple preventative measures. To ensure you aren’t paying more than you need to, read this article. You’ll learn the most common services your health insurance should probably be paying for.
Keep in mind, levels of coverage, managed care networks, and the percentage you pay out of pocket will vary by plan and carrier. Understanding what, if any, of the facility or provider bills you are responsible for is important. Whether you have an individual, small group, or employer based major medical plan, you can expect your plan to help with the following expenses.
- Preventive and Wellness Services
Many diseases, when caught early, have a better chance of being cured or more easily managed. Preventative care helps detect and prevent these serious issues before they become major. Many of the recommended early detection screenings are covered at 100% by most plans. Examples of these screenings include: mammograms, colonoscopies, pap smears, bone density testing, annual physical exams, and vaccinations.
Wellness services are similar to preventive care in that they try to address issues before they get worse. Programs to help you stop smoking or lose weight could be classified as wellness services. Elements that help you manage chronic diseases such as diabetic test strip supplies and heart disease education classes also fall within this categorization. Insurance companies will typically cover these costs or help significantly. Often it can save them money in the long run.
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- Prescription Medications
Most comprehensive health plans have integrated prescription drug coverage. The amount of prescription costs you are responsible for will vary by the type of medication. For example, most plans cover birth control pills completely, but specialty medication like biologics or injectables may have less coverage. For example, insulin injections have notoriously been costly.
Some states restrict how much insurance agencies can require members to pay for specialty drugs to keep medications affordable. However, if you still struggle to afford medications, there are some online options. Birth control, for example, can be ordered online through other providers. Additionally, there are services offering prescription discount cards like GoodRx, Optum Perks, and RxSaver. You’d just need to research which option your pharmacy accepts.
- Outpatient Care
Outpatient care includes services you receive without needing to be admitted to the hospital. These can include visits with your primary care physician, specialists, or urgent care clinic. Your insurance will likely require you to pay a copay, but they should help cover some or most of the cost for outpatient care.
Many services and devices that help you recover from an injury, treat a disability, or chronic condition are also a part of outpatient care. Consider occupational and/or physical therapy or medical devices like a wheelchair. If they are prescribed to help you maintain, obtain, or improve the skills necessary for daily functioning, they’re usually included here.
- Inpatient Care
Inpatient care refers to any medical service that requires a person to be admitted to the hospital. This includes whether it’s for 24-hours or an extended period of time. Even if your insurance plan has a high deductible, inpatient care coverage does a lot of the heavy lifting with hospital bills.
Services covered include complex surgeries, serious illnesses or medical issues that require medical monitoring, and rehabilitation services. Most health plans will also cover much of the inpatient costs of child delivery and aftercare. However, as with any other stay in a hospital or health care facility, you may be responsible for part of the bill.
- Emergency Room Visits
The Affordable Care Act requires all marketplace medical insurance plans to cover emergency room care. Emergency medical conditions include heart attack, stroke, non-stop bleeding, and other such issues. If you’re experiencing an emergency, you don’t need to get pre-approval regardless if the hospital or facility is in or outside of your insurance network. Most comprehensive medical plans follow these guidelines as well.
You should be charged in-network rates for most of the care you receive. Some providers may be outside of your network and can bill you directly for the amount between what they charge and what your health plan pays. Just as with any payments you make, it is important to review all of your emergency room bills and explanation of benefits documents.
- Mental Health and Substance Abuse Disorder Services
Health insurance companies are required by law to cover mental health, behavioral health, and substance use disorder services. The law keeps your insurance provider from charging you a larger copay for mental health services than they do for other routine medical visits. The law also removed annual limits on how many therapy visits your insurance plan will cover.
The law does allow your health insurance company to decide which mental health treatments are considered medically necessary. In some cases this may be to your disadvantage. It is a good idea to check with your provider before your first therapy session. If your plan isn’t covering the cost of your mental health services, you can appeal their decision.
Your health is your most valuable asset. Affordable health insurance is more accessible and important than ever. It’s necessary if you or your family need inpatient and outpatient services for serious conditions. Even if you are in good health today, you can still benefit from the preventative care your insurance covers. Understanding what your health insurance plan pays for helps protect the health and financial future of you and your family.
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