Good Understanding about Health Insurance Coverage

Health insurance plans are designed to help people protect from high healthcare costs, as it is a contract between the policyholders and their insurance carriers. People buy a health plan by paying a premium and in return the insurance company agrees to pay a part of their medical expenses when they will need healthcare. The health insurance policy includes a list of medical benefits like tests, drugs, and treatment services that it covers, the cost of these benefits listed in the policy is paid by the insurance company. The healthcare benefits that are included are called covered services. Besides the covered services the health insurance policy also lists the medical services that are not covered by the insurance company and the policyholders have to pay for any uncovered health care, which they will receive.

Essential Health Benefits

Most of the health insurance plans offered either through a Health Insurance Marketplace or by private health insurance companies operating in federally facilitated marketplaces cover at least ten essential health benefits that are mandatory under the Affordable Care Act. Even the health insurance plans offered by state-run marketplaces are also required to offer these ten essential health benefits. Following are the ten essential health benefits that are covered by most of the health plans:

  • Emergency Services
  • Hospitalization
  • Ambulatory Patient Services
  • Prescription Drugs
  • Maternity and Newborn Care
  • Laboratory Services
  • Mental Health and Behavioral Health Treatment
  • Rehabilitative and Habilitative Services and Devices
  • Preventive and Wellness Services
  • Pediatric Services

Preventive Services

Under the Patient Protection and Affordable Care Act, most of the health plans available through the health insurance marketplace are required to cover a set of preventive services at no cost to the policyholders. Preventive services are essential healthcare services carried out to detect disease or to prevent illness or other health issues. The type of preventive service, which an individual might need depends on his/her age, gender, medical history, and family history. Preventive services are included in all health insurance plans that are purchased after September 23, 2010. Preventive services coverage varies by state, so people should carefully review the preventive services offered in their state.

Types of Preventive Services

Different types of preventive services are offered to adults, women, and children. The table below will give a clear idea about the preventive services offered to adults, women, and children.

Adults Preventive Services Women Preventive Services Children Preventive Services
Alcohol misuse screening and counseling Breast cancer mammography and chemoprevention counseling Children’s immunization vaccines
Aspirin use to prevent cardiovascular disease Breastfeeding counseling Congenital hypothyroidism screenings for newborns
Blood pressure screening Cervical cancer screening Depression screening
Cholesterol screening Contraception Developmental screening
Colorectal cancer screening for adults over 50 Domestic and interpersonal violence screening and counseling Dyslipidemia screening
Depression screening Certain items and services for pregnant women Fluoride chemoprevention
Diet counseling Gestational diabetes screening Hearing screening for newborns
HIV screening Osteoporosis screening Height, weight, and body mass index measurements
Immunization vaccines Rh incompatibility screening Hematocrit or hemoglobin screening
Obesity screening BRCA counseling for women at higher risk Iron supplements
Sexually transmitted infections prevention counseling Lead screening
Syphilis screening Vision screening
Tobacco use screening Behavioral assessments
Type 2 diabetes screening

Difference Between Medical Necessity and Medical Benefit

People purchasing health plans should keep in mind that medical necessity and medical benefits are not the same. A medical benefit is healthcare services that are covered by health plans and medical necessity is something that a doctor considers necessary for a patient. In some cases, a doctor may decide that a person needs medical care that is not covered under his/her health plan. Generally, insurance companies include tests, drugs, and services, which they think will be required by most of the patients. So, there may be the case when a medical service, drug or test required by a person might not be covered under his/her plan.

What should Insured do?

Doctors practicing in the US try to familiarize themselves with the healthcare coverage offered by their patient’s insurance carrier. With so many health plans available in the market it becomes difficult for the doctors to know about the coverage of every plan. Therefore, by well understanding their insurance coverage insured can help their doctor recommend medical care that is covered under their plan. Insured should be aware of the following things:

  • Insured should take time and carefully read their policy documents to know about the coverage that insurance companies will pay before they decide to receive a service, get tested, or fill a prescription.
  • Some of the healthcare first need to be approved by the insurance company before receiving those medical care from the doctors. So the insured should be aware of those medical services that require prior approval of the insurance company.
  • Insured should remember that decision related to coverage is made by the insurance companies and not the doctor. So, in case of any query about the coverage, the insured should get in touch with a representative of their insurance company to clear their doubts.

Uncovered Services

Most of the healthcare services usually suggested by the doctors are covered by health plans but some of the medical services may not be covered. Insured should be aware that if they have to undergo a test or treatment, or need to get a prescription filled for a drug that is not covered, then their insurance company will not pay the bill. It is termed as denying the claim. Though insured can still receive the treatment recommended by their doctor but they will need to pay for it themselves. Nevertheless, in case of denial of the claim, policyholders have the right to appeal the decision but before appealing, they should be aware of the appeal process of their insurance company. This is generally discussed in the plan handbook. Policyholders should also seek their doctor’s opinion and if their doctor thinks that it is right to appeal then even the doctor might help them through the appealing process.

Questions for Doctors

People planning to purchase health insurance should visit doctors of their area to check out a few questions that will help them pick the best health plans having ideal coverage.

  • If certain types of health insurance are not accepted by them?
  • Type of coverage that will be significant for them and their families.
  • An Individual can check whether that doctor is in their insurance company’s network of providers.

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