2024-01-01 · personal, health

Health Coverage

Overview

Health insurance helps cover the cost of medical care, from routine checkups to major procedures. Plans differ by network, cost-sharing structure, and covered services, so comparing benefits and total out-of-pocket costs is essential.

What health insurance typically covers

• Preventive care: annual physicals, screenings, and vaccines.
• Primary and specialist care: office visits, diagnostics, and referrals.
• Hospital services: inpatient stays, surgeries, and emergency care.
• Prescription drugs: medications under a plan’s formulary.
• Mental health services: therapy, counseling, and inpatient treatment.

Common exclusions and limitations

• Out-of-network costs: higher coinsurance or no coverage at all.
• Non-formulary drugs: may require prior authorization or pay full price.
• Cosmetic procedures: generally excluded unless medically necessary.
• Coverage limits: some services have visit caps or require referrals.

Key cost components

• Premium: what you pay monthly to keep coverage active.
• Deductible: amount you pay before coverage begins (except preventive care).
• Copay/coinsurance: your share after the deductible.
• Out-of-pocket maximum: the annual cap on covered expenses.

How to compare plans

1. Check network fit: verify your doctors and preferred hospitals are included.
2. Estimate total cost: add premiums and typical out-of-pocket spending.
3. Review drug coverage: ensure your medications are on the formulary.
4. Consider plan type: HMO, PPO, or HDHP depending on flexibility needs.

Tips for choosing coverage

• If you expect higher medical use, a higher premium with lower out-of-pocket costs can reduce total spend.
• For low expected use, a high-deductible plan paired with an HSA may offer savings.
• Always read the summary of benefits and coverage (SBC) for details.

Frequently asked questions

Is preventive care really free? Often yes, when using in-network providers, but confirm your plan’s preventive services list.

Can I keep my current doctor? Only if they are in-network for the plan you select; check before enrolling.

What happens if I go out of network? Many plans reduce or deny coverage, and you may be responsible for most costs.