One of the most common questions people ask when seeing a new doctor, changing medicines or trying a new treatment option is, “Will this be covered?”
What does health insurance cover?
If a service is covered, it means your health plan will pay for some or all the cost. Covered services typically include regular office visits with your doctor, tests, urgent and emergency care, hospital stays, prescription drugs, medical equipment and more. In most cases, your doctor also needs to be a part of your insurance network – generally, this means they’re on the list of doctors that take your insurance.
How much your health plan pays for depends on what type of care you use and where you get it. Some services are fully covered under many plans, like going to the doctor for preventive care. For others, like seeing the doctor for a sinus infection or filling a prescription for antibiotics, you’ll pay some cost out of pocket. The amount you pay depends on the type of plan you have and whether you’ve met your deductible.
To get the most out of your coverage, use services your health plan covers and go to providers in your network whenever possible.
How to find out what kind of health insurance you have
When you don’t use your health insurance often, it’s easy to forget what kind of plan you have and what’s covered. Plans come in many forms, and it’s important to know how yours works so you can get the most out of your coverage.
Common plan types include:
- Preferred provider organization (PPO) plans: A PPO plan offers coverage through a specific network of doctors, clinicians and specialists. Most PPO plans allow you to see providers both in and out of the network, but you pay less out of pocket when going to in-network doctors.
- Health maintenance organization (HMO) plans: HMO plans limit coverage to health care services provided by doctors who are in your network, which are often specific to the area you live or work in. These plans typically don’t cover out-of-network services outside of emergencies.
- High-deductible health plans (HDHP): HDHPs feature lower premiums and higher deductibles. You’ll pay less each month for insurance and more out of pocket when you receive care. An HDHP is often paired with a health savings account (HSA).
- Health savings accounts (HSAs): HSAs are not plans. Instead, they’re accounts that work alongside an HDHP. With an HSA, you deposit pretax money into your account to use on specific medical expenses.
To find out what your plan covers or what kind of plan you have, contact your health insurance provider’s Member Services team. The phone number is usually on the back of your insurance ID card.
If you get your insurance through work, you can also contact your human resources team or check your enrollment information.
How do I check if my health insurance covers something?
Each health insurance plan covers different doctors, clinics, prescriptions and services, even among plans provided by the same insurance company. Some members are surprised to learn that their plan covers things they didn’t expect, like their chiropractor visits and pumps for breastfeeding moms.
Make sure to confirm with your insurance provider that the care and provider you want are covered before you make an appointment. If possible, it’s also a good idea to research the amount you might have to pay.
Here are five places to go for information:
- Your Summary of Benefits and Coverage (SBC) – Ask you insurance company for a copy of your plan’s Summary of Benefits and Coverage, sometimes called an SBC. This is a standard document that all plans are required to have. It lists the services the plan covers and how much; you can see a sample SBC here (PDF). If you’re a HealthPartners member, you can easily sign in to review your coverage.
- Your plan’s cost estimation tools – Understanding health care costs can be complex, but some plans offer easy-to-use price transparency tools that can help estimate what you might pay out of pocket for a certain service at a certain location. These tools can be some of the best places to look to get an idea of not only what’s covered, but also how much you can expect to spend. Many HealthPartners members can sign in to access our cost estimate tools online.
- Your doctor search tool – Use your plan’s network, provider or doctor search tool. Different plans cover different doctors, specialists and clinics, so it’s important to make sure that the doctor you want to see is covered. If you’re a HealthPartners member, I recommend signing in to search your network – it’s the easiest (and fastest) way to find covered providers and locations.
- Your plan’s formulary (drug list) – If your plan includes prescription drug coverage, it’ll have a list of the medicines it covers, also known as a formulary or drug list. Review the list to make sure the prescriptions you need are included and if they need any special approvals (pre-authorizations). Some plans also offer a calculator tool to help you find the lowest prices on prescriptions from specific pharmacies or in different quantities; HealthPartners members can compare prescription costs online.
- Your Member Services team – There’s no such thing as a silly question. If you have any questions about what your plan covers, contact your insurance company. Member Services representatives are there to answer exactly these types of questions. They can tell you whether a doctor, prescription or service is covered, plus how much your insurance will pay. If you’re a HealthPartners member, you can see personalized contact options online – you can also call the number on the back of your member ID card.
You're reading the "Getting started with your plan" series
Have a health plan but not sure what to do next? This series can help you get started.
Part 1: How to get the most out of your health insurance
Part 2: How to figure out what your health insurance plan covers