Health insurance is a contract between an individual and an insurance company. It helps individuals and families pay for medical costs. Health insurance reduces the risk of people having to pay very high health care costs out of pocket. A person pays a fixed amount each month, called the premium, to maintain coverage and reduce the amount that must be paid if someone in the family gets sick or injured and must go to the doctor. With health insurance, both the insurance company and the individual pay for health care.
Over the past few years, some people have purchased and are using health insurance for the first time. When you go to the doctor or hospital to receive treatment, it is important for you to know what is and is not covered by your health insurance plan. Covered means that the insurance company will pay some or all of the cost of the service. Knowing what is and is not covered will help you know how much you will have to pay for health care services.
Health insurance covers a variety of health services, such as:
• Outpatient care at a hospital, emergency care, and hospital services (e.g., surgery and overnight stays in the hospital)
• Pregnancy and maternity care (before and after the birth of a child) and pediatric services
• Mental health and substance addiction-related (e.g., drug and alcohol) services
• Prescription medications, devices and services that help people mentally or physically recover from injuries, disabilities, or chronic conditions
• Laboratory services, preventive and wellness services, and chronic disease management
What is preventive health care?
To stay as healthy as possible, it is important to live a healthy lifestyle. A healthy lifestyle includes practices like eating healthy, exercising regularly, getting enough rest and sleep, and removing toxins from the home. It also includes using preventive health care services provided through health insurance. Most people know that they should seek medical attention when they are ill or injured. However, many people do not think about using health insurance to prevent, or reduce, the chances of becoming ill. Using the preventive health care services covered by health insurance is important to staying healthy.
Preventive health care can keep you from getting sick or help you to detect an illness or disease early, so it can be treated more easily and at a lower cost. Examples of preventive health care include cancer screenings to find cancer before it spreads and getting vaccines or immunizations to prevent harmful viruses like the flu or measles.
Most preventive health care services are covered at no cost. This means that after you pay the premium to have health insurance coverage, the insurance company pays the full cost for preventive services. You do not pay the deductible, copayment, or coinsurance. However, services are usually only free when provided by in-network health care providers, which are physicians, hospitals, pharmacies, suppliers, etc. that the health insurance company has contracted with to provide health care services. In-network providers are sometimes referred to as “preferred providers” or “participating providers.” In-network providers have signed up to work with the health insurance company. In-network providers can change over time, so it is important to check that the provider is still in-network every time you schedule appointments.
What preventive health care services are covered?
Each health insurance plan is different. It is important to know what preventive services are covered under your plan. It is also important to learn when the services are covered at no cost. Your health plan’s “Summary of Benefits and Coverage” gives you some information about what is covered. If you have questions, contact your health insurance company. Some health care providers have medical billing staff who are familiar with different insurance plans, so they may also be able to answer questions. Keep in mind that it is your responsibility to know what services are paid for by your health insurance company. Ultimately, you may be responsible for paying the amount that your health care plan does not pay.
Below are some examples of preventive services covered by health insurance:
• Abdominal aortic aneurysm screening
• Hepatitis B screening • Alcohol misuse screening
• Hepatitis C screening • Blood pressure screening
• HIV screening • Cholesterol and lipid screening
• Vaccines • Colorectal cancer screening
• Lung cancer screening • Depression screening
• Obesity screening • Type 2 diabetes screening
• Pap and/or pelvic exams • Sexually transmitted infection screening
• Tobacco use screening
In addition to preventive health care services, some health insurance plans also offer various wellness services that can lead to better health .
Preventive health care services help people to prevent illnesses or diseases by getting screenings and annual checkups. Wellness services help people maintain or improve health and fitness by giving people support to stop smoking, lose weight, eat healthy, reduce stress, exercise regularly, and provide management for mental or physical illnesses such as depression, diabetes, and asthma. Wellness services can include discounted gym membership fees, nutrition and stress reduction classes, as well as one-on-one access to nurses, dietitians, mental health counselors, and other types of coaches for various health-related issues. Wellness services also usually provide support to pregnant women and individuals preparing for surgery. Many wellness services are provided over the phone and/ or online.
The types of preventive services covered by health insurance vary based on age and gender. There may be a limit on the number of times and how often some services are covered. Services may also be limited to people who are at high risk for an illness. For example, colon cancer screening is usually free for adults over 50, and it is usually only covered every 10 years unless you are having a problem. A no-cost screening for an abdominal aortic aneurysm is usually a one-time screening for men of certain ages who have smoked. Osteoporosis screening may be free only for women over age 60 based on risk factors. There are usually free screenings for women (e.g., cervical and breast cancer screenings), pregnant women (e.g., anemia and gestational diabetes), and children (e.g., developmental screening at different ages).
What can you do?
Take an active role in managing your health. Get your annual physical exam each year. Talk with your doctor about the services you need and take advantage of all the preventive and wellness services covered through your health insurance. You can also go to https://healthfinder.gov/ and enter your age and gender in myhealthfinder to get a list of recommended preventive services for your age and gender. Then check your health insurance coverage to find out if, when, and under what circumstances each service on your recommended list is covered at no cost. After you have used your preventive care benefits, make sure you have been billed correctly. When you receive your bill from your health care providers and/or your explanation of benefits (EOB) from the insurance company, check to make sure you are not being charged for services that are supposed to be free. Don’t wait until you are sick or injured to go to the doctor. You should use the preventive health care and wellness benefits you have with your health insurance to prevent or reduce your chances of getting sick. Preventive health care is essential to staying healthy.
Preventive health care: Health care services that can prevent or reduce the chance of an illness or disease or find them at an early stage
Premium: The dollar amount you pay each month to have health insurance
Deductible: The dollar amount you pay for medical services before the insurance company begins to pay for services
Copayment: The dollar amount you pay for medical services when you go to a doctor or hospital
Coinsurance: The percent of medical costs you pay after the deductible
In-network providers: Health care providers that the insurance company contracts with to provide services
Status and Revision History
Published on Oct 09, 2017