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. 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 purchased both through the Marketplace and off-exchange offers many basic benefits at no cost.
♦ One of the benefits of health insurance through the Marketplace is that all health insurance plans cover the same set of essential health benefits, even for a pre-existing health condition.
All plans offered at the Marketplace cover the same set of essential health benefits.
Every health plan must cover the following services:
- Office visits
- Laboratory services
- Ambulatory patient services (outpatient care)
- Emergency care
- Pregnancy, maternity, and newborn care
- 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
♦ Adult dental and vision coverage aren’t essential health benefits so most plans will not 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 they tend to be more for emergency than for routine preventive services.
♦ A more traditional dental insurance plan is available through the Marketplace as a 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 and services for male reproductive capacity, like vasectomies.
Special Birth Control Benefits Rules
Churches & Houses of Worship
Health plans sponsored by certain exempt religious employers, like churches and other houses of worship, don’t have to cover contraceptive methods and counseling.
If you work for an exempt religious employer and use contraceptive services, you may have to pay for them out-of-pocket. Contact your employer or benefits administrator for more information.
Non-profit Religious Organizations
Non-profit religious hospitals and institutions of higher education that certify they have religious objections to contraceptive coverage don’t have to contract, arrange, pay, or refer for contraceptive coverage.
• If your health plan is sponsored or arranged by this type of organization, an insurer or third party administrator will make separate payments for contraceptive services that you use.
• You’ll have access to contraceptive services without a copayment, coinsurance, or deductible when they are provided by an in-network provider.
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 abuse treatment
Your specific behavioral health benefits will depend on your state and the health plan you choose. You will see a full list of what your plan covers, including behavioral health benefits, when you read you plan’s Summary of Benefits and Coverage (SBC). You should 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 cannot deny you coverage or charge you more just because you have any 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 cannot 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 abuse benefits on the one hand, and medical and surgical benefits on the other.
This generally means limits applied to mental health and substance abuse services can’t be more restrictive than limits applied to medical and surgical services.
Most organ transplantation procedures are expensive. Because of their high cost, many public and private insurers are reluctant to cover them.
• Some insurance companies are reluctant to pay for certain transplants, arguing that they are "experimental" or "investigational." Pancreas, lung, and heart-lung transplants are often classified as such.
The concern is that insurers base their decisions purely on cost, not benefit. Insurers are hesitant to extend coverage to procedures they view as ineffective.
Transplantation programs performing pancreas, heart-lung, and lung transplantation, therefore, do so at some risk. They may not be reimbursed for the procedures they perform, or, more likely, the level of payment received is likely to be substantially below actual hospital costs.
♦ To control costs, insurers have begun to designate transplantation centers. In doing so they limit coverage and reimbursement to programs they regard as "centers of excellence."
Will my insurance covers an organ transplant?
The only way to find out is to ask your insurance company. When inquiring be sure to record the date and name of the person you spoke to. Ask for a copy of your insurance policy. It may be referred to as 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 treat follow-up care?
Do not forget
♦ If you purchase health insurance through the Marketplace or off-exchange you have the opportunity to select a new plan every fall without regard to pre-existing conditions.
If find your current plan does not cover a transplant you are considering then open enrollment is the time to review new plans.
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. Bone marrow and cornea transplants under certain conditions.
Original Medicare allows you use any facility or transplant doctor in the nation that accepts Medicare. This is not the case with many of the Advantage plans.
Most Medigap plans work in union with 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 plans cover some of the costs for transplants. Some plans rely upon Medicare to make the determination as whether the transplant is qualified. Many Advantage plans require their own separate prior authorization procedure be followed.
The biggest concern with Advantage plans is that the majority are HMO type plans. They will have 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.
Non-Covered Medical Expense
What health insurance does 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 is normally covered may at times be refused.
♦ If the service was not necessary for your particular condition. This is a grey area that could get resolved favorably if the treating physician can provide documentation justifying the service.
Services like cosmetic surgery are never covered by insurance.
♦ A responsible provider will inform you before having the treatment. Some may even ask you to sign a statement called a Non-Covered Service form acknowledging that you understand your insurance does not 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, except if you signed a statement prior to 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 stack of documents you are rushed to sign is unethical.
• You are 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 are not obligated by contract to write-off these charges.
How do I understand what is not covered?
Insurance companies do not make it easy to understand the finer details of what is NOT covered. Every plan must provide a Summary of Benefits Coverage (SBC). This document is what it says, a summary. They state in general terms what is covered. But they almost never say what is not covered.
♦ To learn what is not covered you need to seek out the Certificate of Coverage document. 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 does not cover. Sometimes it called Limitation and Exclusion. Other times it is called Non-Covered Services.
♦ Every plan has non-covered services. Many non-covered services are pretty universal among plans.
Unfortunately, there are many plans which have taken this to an extreme and have a 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 partial list of exclusions gathered from a well-known United HealthCare plan. The plan we inspected has a multi-page listing of limitation 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 which 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 are not covered
Except as provided under Child Wellness services, for the purposes of prescribing corrective lenses. Some plans are covering an eye exam perform by an Ophthalmologist. And a few are starting to cover refractions (prescriptions for glasses).
- 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/shower chairs
Not covering many of these services does make sense.
♦ Prior to 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 incurring great expense.
The outrage over such insurance practices was a driving force behind requirements set forth by the Affordable Care Act to guarantee Minimum Essential health benefits and to require insurance companies to sell Qualified Health Plans.