What's Covered by Your Health Insurance?

The healthcare services your medical insurance covers can vary from plan to plan, so it's important to read your enrollment information carefully - as well as your policy after you've enrolled.

Here are some things to look for in your policy:

  • Preventive care: Many plans - such as a fee for service (FFS) plan - won't cover an annual exam or well baby check, or other illness prevention care. However, "managed care" plans - like Preferred Provider Organization (PPO), Point of Service (POS), and Health Maintenance Organizations (HMO) plans - do emphasize prevention in various ways:

    • Checkups ["well visits"] are typically covered
    • "Medically necessary" services are covered, but these may differ with each plan
    • Prescription medications may or may not be covered, and there's likely a requirement to use a generic instead of a name brand drug, if available

  • Pre-existing condition: If you've have a chronic health condition, or some other pre-existing health concern, your health plan may have a "waiting period" of from one to six months, or even longer, before you can be covered for that condition - but only if you've not had health insurance coverage for longer than 63 days. This could occur if you left your job but didn't start a new one right away, and didn't have COBRA, or an individual insurance plan, or coverage with a spouse in that time.

  • Drug benefit exclusions: Hair growth stimulants, skin treatments, food supplements, and other cosmetic or nontraditional drugs are often excluded from health coverage. Sometimes, a policy won't cover birth control.

  • Cosmetic surgery: Unless there's a medical need for cosmetic or reconstructive surgery, this is rarely covered by health insurance.

  • Complementary and alternative medicine (CAM): Other than chiropractic care, CAM therapies aren't often covered by health insurance, but some exceptions are beginning to occur - such as some limited coverage for acupuncture. Sometimes an insurer will negotiate discounts for massages, acupressure, biofeedback, and other treatments that are used along with or instead of conventional medicine.

  • Home care and private nursing: It's not uncommon for a family to need private duty nursing or home health aids, but these are often not included in health insurance.

  • Mental health and substance abuse treatment: These treatments may or may not be covered, but if they are, they're likely to need a referral from your doctor.

  • Lifetime maximum: Your insurance company may place a limit on how much coverage it will pay for you during your lifetime - often around $1 million or more.

Learn more about how Group Health Insurance works.

Health Insurance Glossary

Watch Healthcare Video: How does health insurance work?