Benefits - What is Covered
Benefits refers to health care items and services covered under a health insurance plan.
No one plans to get sick or hurt, but most people need medical care – like a doctor visit, prescription drugs, lab tests, physical therapy, or counseling – at some point.
These services can be very expensive.
It is important to know what your plan considers as covered medical services; your benefits.
Jump ahead to: Organ Transplants and Non-covered Medical Expenses
What health insurance pays?
If something happens that requires surgery or emergency medical care, it's really important to have health insurance. According to HealthCare.gov, fixing a broken leg can cost up to $7,500, and the average cost of a 3-day hospital stay is around $30,000.
Health insurance bought through the Marketplace or off-exchange covers many preventive services at no cost.
♦ One of the benefits of health insurance through the Marketplace is that all plans cover the same set of essential health benefits, even for a pre-existing health condition.
Every individual and small group plan, whether bought on the Marketplace or off-exchange, must cover the following services:
- Office visits
- Laboratory services
- Ambulatory patient services (outpatient care)
- Emergency care
- Hospitalization
- Surgeries
- Pregnancy, maternity and newborn care
- Mental health and substance use disorder services
- Preventive and wellness services for adults, children and women
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Chronic disease management
- Pediatric services, including oral and vision care
• Large employer and self-insured plans don't have to cover every one of these, but most do. And if they cover them, they can't put yearly or lifetime dollar limits on them.
♦ Adult dental and vision coverage aren't essential health benefits, so most plans won't offer this coverage unless an additional premium is paid.
Some plans available through the Marketplace offer additional benefits like chiropractic and acupuncture services.
A few plans offer limited dental coverage, but for the most part it tends to be more for emergencies than for routine preventive services.
♦ A more traditional dental insurance plan is available through the Marketplace as separate insurance. Choosing or not choosing a dental plan through the Marketplace does NOT affect any premium tax credit (subsidy) you may have.
→ The subsidy is for use in paying the premium for health insurance only.
Plans must also include the following benefits:
Plans in the Health Insurance Marketplace must cover contraceptive methods and counseling for all women, as prescribed by a health care provider.
Plans must cover these services without charging a copayment or coinsurance when provided by an in-network provider, even if you haven't met your deductible.
Covered contraceptive methods
FDA-approved contraceptive methods prescribed by a woman's doctor are covered, including:
• Barrier methods, like diaphragms and sponges
• Hormonal methods, like birth control pills and vaginal rings
• Implanted devices, like intrauterine devices (IUDs)
• Emergency contraception, like Plan B® and ella®
• Sterilization procedures
• Patient education and counseling
Plans are not required to cover drugs to induce abortions or services for male reproductive capacity, like vasectomies.
Special Birth Control Benefits Rules
Employers with religious or moral objections to birth control may not have to cover it. This includes churches and houses of worship, but also some religious nonprofits and even some private companies.
Some of these employers choose an "accommodation," where the insurer or plan administrator pays for birth control separately, at no cost to you. Others take a full exemption, and then you may have to pay for birth control yourself.
♦ If you work for a religious organization or a company with religious owners, ask your benefits administrator how birth control is handled before you count on it being free.
Most Marketplace plans must provide breastfeeding equipment and counseling for pregnant and nursing women.
Health insurance plans must provide breastfeeding support, counseling and equipment for the duration of breastfeeding. These services may be provided before and after birth.
This applies to Marketplace and off-exchange health insurance plans, except for grandfathered plans.
Your health insurance plan must cover the cost of a breast pump. It may be either a rental unit or a new one you'll keep. Your plan may have guidelines on whether the covered pump is manual or electric, the length of the rental, and when you'll receive it (before or after birth).
But it's up to you and your doctor to decide what's right for you.
Your insurance plan will often follow your doctor's recommendations on what's medically appropriate. Some insurance plans may require pre-authorization from your doctor. Talk to your doctor to find out what this means for you.
All plans must cover:
• Behavioral health treatment (psychotherapy and counseling)
• Mental and behavioral health inpatient services
• Substance use disorder treatment
Your specific behavioral health benefits will depend on your state and the health plan you choose. You'll see a full list of what your plan covers, including behavioral health benefits, when you read your plan's Summary of Benefits and Coverage (SBC). Be sure to read the SBC carefully before selecting a plan.
Pre-existing mental and behavioral health conditions are covered, and spending limits aren't allowed
• Marketplace plans can't deny you coverage or charge you more just because you have a pre-existing condition, including mental health and substance use disorder conditions.
• Coverage for treatment of all pre-existing conditions begins the day your coverage starts.
• Marketplace plans can't put yearly or lifetime dollar limits on coverage of any essential health benefit, including mental health and substance use disorder services.
Parity protections for mental health services
Marketplace plans must provide certain "parity" protections between mental health and substance use disorder benefits on the one hand, and medical and surgical benefits on the other.
This generally means limits applied to mental health and substance use services can't be more restrictive than limits applied to medical and surgical services.
Organ Transplants
Organ transplants are very expensive, and insurers watch them closely. Most plans cover common transplants, but almost all require prior authorization, and many will only pay if you use one of their approved transplant centers, often called "centers of excellence."
♦ Insurers may still refuse newer or less common procedures by calling them "experimental" or "investigational." If that happens, ask your transplant team for help with an appeal.
Will my insurance cover an organ transplant?
The only way to find out is to ask your insurance company. When you call, be sure to write down the date and the name of the person you spoke to. Ask for a copy of your insurance policy. It may be called a Certificate of Coverage.
You may want to ask your insurance company several questions, such as:
- What specifically does your plan cover related to transplants?
- Are there limits on what the plan will pay?
- Will your plan cover transplant services such as organ procurement and testing?
- Will your plan cover immunosuppressant medications?
- What is the approval process?
- How long does it take to get approval?
- Will transportation and lodging expenses be covered?
- How does your plan handle follow-up care?
Do not forget
♦ If you buy health insurance through the Marketplace or off-exchange, you have the chance to select a new plan every fall, without regard to pre-existing conditions.
If you find your current plan doesn't cover a transplant you're considering, open enrollment is the time to review new plans.
Medicare
Medicare Part B (Medical Insurance) covers doctor services for certain organ transplants. And Medicare Part A (Hospital Insurance) covers the transplant facility costs.
Medicare covers heart, lung, kidney, pancreas, intestine and liver transplants, and bone marrow and cornea transplants under certain conditions.
• Medicare Part B also covers immunosuppressant drugs if Medicare paid for your transplant. Since 2023, kidney transplant patients who lose Medicare coverage can keep immunosuppressant drug coverage through a program called Part B-ID.
Original Medicare allows you to use any facility or transplant doctor in the nation that accepts Medicare. This is not the case with many Advantage plans.
Medigap
Most Medigap plans work alongside Original Medicare and will pay part of transplant costs, as long as the transplant is Medicare-approved.
Medigap policies can be used at any facility in the nation that accepts Medicare.
Medicare Advantage
Medicare Advantage plans cover some of the costs for transplants. Some plans rely on Medicare to decide whether the transplant qualifies. Many Advantage plans require their own separate prior authorization.
The biggest concern with Advantage plans is that the majority are HMO-type plans with limited networks of providers. Transplant facilities in other parts of the country may be unavailable to you.
Do not forget
If you find your Advantage plan is too restrictive, in the fall you have the option to change plans or even return to Original Medicare.
♦ Be careful. In most states, once you've been in a Medicare Advantage plan for more than a year, Medigap insurers can ask about your health and turn you down if you try to switch back. If you're facing a transplant or another serious condition, check your Medigap options before you leave Advantage.
Non-Covered Medical Expense
What does health insurance not cover?
There will be times when your insurance company will refuse to pay for a medical service. Many times a claim can be resolved by your provider submitting additional information. In a few cases, you may need to file an appeal.
A service that's normally covered may at times be refused.
♦ That can happen if the service wasn't necessary for your particular condition. This is a gray area that could be resolved in your favor if the treating physician can provide documentation justifying the service.
Purely cosmetic surgery is almost never covered by insurance.
♦ A responsible provider will tell you before you get the treatment. Some may even ask you to sign a statement called a Non-Covered Service form, acknowledging that you understand your insurance doesn't cover the service.
♦ If you use an in-network provider, you have protection from a lot of non-covered services. Most provider contracts prevent billing the patient for non-covered services, unless you signed a statement before receiving the service.
Unfortunately, some providers have started slipping in general forms for patients to sign, acknowledging that they might receive some services not covered by insurance. Hiding a general blanket form in a stack of documents you're rushed to sign is unethical.
• You're responsible for noticing what you sign. Best advice: if you find a form like this, refuse to sign it. After that, find a new doctor.
♦ Using an out-of-network provider puts you at great risk of having to pay for non-covered services. Out-of-network providers aren't obligated by contract to write off these charges.
• Since 2022, the No Surprises Act protects you from most surprise out-of-network bills for emergency care, and from out-of-network doctors like anesthesiologists at an in-network hospital or surgery center. It doesn't cover everything, so still check networks before planned care.
How do I find out what's not covered?
Insurance companies don't make it easy to understand the finer details of what's NOT covered. Every plan must provide a Summary of Benefits and Coverage (SBC). This document is what it says, a summary. It states in general terms what's covered.
The SBC includes a short list of excluded services, but it's far from complete.
♦ To learn everything that's not covered, you need to seek out the Certificate of Coverage. This is usually a many-page document, more like a book.
The jargon in this document weighs everyone down. There will be a section listing things the plan doesn't cover. Sometimes it's called Limitations and Exclusions. Other times it's called Non-Covered Services.
♦ Every plan has non-covered services. Many non-covered services are pretty universal among plans.
Unfortunately, many plans have taken this to an extreme, with very extensive lists of exclusions. Most people never learn about exclusions until they receive a service and their insurance company refuses to pay.
Below is a partial list of exclusions gathered from a well-known UnitedHealthcare plan. The plan we inspected has a multi-page list of limitations and exclusions covering medical services, prescription drugs and pediatric care.
Not covered if:
- Not reasonable and necessary
- Personal comfort
- Hearing aids and auditory implants
- Cosmetic surgery
- Services not medically necessary
- Services that are experimental, investigational or for research purposes
- Services exceeding the amount of benefits available for a particular service
- Elective medical or surgical procedures
- Vision examinations or testing (usually not covered, except as provided under Child Wellness services for prescribing corrective lenses)
- Dental services, except if related to bodily injury or sickness
- Any treatment for obesity
- Treatment of nicotine habit or addiction, except as eligible for coverage under preventive services
- Hair transplants or implants
- Genetic testing
- Personal hygiene equipment, including bath and shower chairs
- Some plans are covering an eye exam performed by an ophthalmologist. And a few are starting to cover refractions (prescriptions for glasses).
• Some of these exclusions have exceptions. For example, obesity counseling and certain genetic testing, like BRCA testing for women at higher risk, are covered as preventive services.
Not covering many of these services does make sense.
♦ Before the Affordable Care Act, many insurance companies sold bare-bones protection to unwitting people desperate for lower-cost health insurance. Many people learned later they could receive few basic services without great expense.
The outrage over such insurance practices was a driving force behind requirements in the Affordable Care Act to guarantee Minimum Essential health benefits and to require insurance companies to sell Qualified Health Plans.
♦ Bare-bones plans haven't gone away completely. Short-term health plans are still sold, and they don't have to follow these rules. Read the fine print before you buy one.
