Navigating the System

Empower yourself as a patient, and learn how to get the most out of your benefits. Each plan is different, so this section of our guide will help you understand what it is that you should look for when you receive your insurance information.  This section will help you navigate the health care system when you need care.

Topic Area: Getting care, what's covered

What do health plans cover?

Keep in mind, health plans only cover what they consider “medically necessary.” For example, plastic surgery would not be covered just because you want to improve the way you look. But, it would likely be covered to fix a problem (even if afterwards you like your nose better).                                     

Major medical type commercial health insurance is linked to covering health care services, not disease conditions.  When the service is medically necessary and covered under the benefit plan, there should not be limitations based on the underlying health care condition.                                                                                               

If your plan is covered by the Affordable Care Act (as a Marketplace plan), it has to offer these 10 types of care:

  • Ambulatory patient services, such as care provided at a clinic or same-day surgery center
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and Habilitative services and devices
  • Laboratory services
  • Preventive and wellness services including chronic disease management
  • Pediatric services, including dental and vision care

Review your Summary of Benefits and Coverage Document

Once you enroll in a health insurance plan, you will be given a summary of benefits and coverage document. It will tell you:

  • Which services will and will not be covered
  • How much you and the plan will pay for different kinds of services
  • About the plan’s provider network, and how benefits differ in- or out-of-network
  • When you need to get referrals or preauthorization
  • The definitions of words that have special meanings (it’s a good idea to get familiar with these)
  • About your rights
  • Where to get your questions answered

You can call your plan’s customer service any time to ask for a printed copy free of charge.


Was this answer helpful?