What Does Health Insurance Cover?

Updated: May 22, 2024

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Health insurance typically covers essential services, including annual check-ups, emergency care, hospitalizations, maternity care, mental health treatment, prescriptions, rehabilitation, lab tests, pediatric services and chronic disease management. Preventive services such as annual check-ups are usually covered at no out-of-pocket cost to the policyholder.

To find out what is covered under your plan, review the Summary of Benefits and Coverage, check for in-network providers and prescription coverage and understand how cost-sharing between you and your insurer works. Stay updated through your insurer or employer for any changes in coverage.

Table of Contents

What Your Health Insurance Covers

Your health insurance typically includes a range of essential benefits, especially after the implementation of the Affordable Care Act (ACA). For individual and small group plans, particularly those offered through public exchanges like the federal Health Insurance Marketplace, ten core health benefits are mandated. These include preventive services, mental health care, prescription drug coverage and pediatric services.

It's important to note that while these essentials are standardized, specific coverage details may differ by state. Annual out-of-pocket limits — beyond which the insurer covers 100% of costs for essential benefits — vary by plan. There are no lifetime or annual maximum payment limits on these benefits.


Coverage and limits vary significantly between different types of plans and states. Private insurance plans generally offer the most robust coverage, whether they're purchased on the marketplace, directly from an insurance company or through an employer. If you're getting insurance through your employer, your choices will be limited to the plans it offers, and marketplace plans vary by state.

Meanwhile, government-sponsored insurance may also provide varying coverage depending on your state. Medicare caters to older adults and individuals with disabilities. Medicare has four parts: in which Parts A and B cover hospital and medical services, and optional Parts C and D offer extended benefits. Medicaid offers coverage for low-income individuals, with specifics varying by state.

Commonly Covered Services

Health insurance provides coverage for a range of essential health services designed to maintain or improve health and wellbeing. Most health insurance plans typically cover the following:

10 Essential Health Benefits

All plans available through federally facilitated health insurance marketplaces are required to offer 10 essential benefits, and most plans available for purchase directly from insurance companies cover these as well.

  1. Regular check-ups, screenings and vaccinations for disease prevention and health maintenance.
  2. Immediate medical attention for emergency conditions.
  3. Hospital treatments, including surgeries and overnight stays.
  4. Maternity and newborn care during and after pregnancy.
  5. Behavioral health treatment for mental health and substance use disorders.
  6. Prescribed medications covering various health needs.
  7. Rehabilitation services, including physical and occupational therapy and necessary devices.
  8. Laboratory services like blood and urine tests for diagnosis and monitoring.
  9. Pediatric services ensure health coverage for children, including dental and vision care.
  10. Management and care for chronic diseases, helping to maintain health over time.

Two other mandatory benefits include coverage for contraceptives and counseling, as well as breastfeeding support, which involves breast pump rental and lactation counseling.

The specific services covered within these broad benefit categories will differ according to your state's regulations, so always read the policy terms carefully.

Preventive Services

All marketplace health plans, and many private health insurance plans cover preventive services without out-of-pocket like copayments or co-insurance, irrespective of whether the yearly deductible has been met. However, these services are free only when accessed through in-network providers.

Preventive service coverage is broken down into three categories:

Preventive Services for Adults

Most health insurance plans cover preventive services for adults, including a diverse range of screenings, counseling and interventions. These services address specific health risks and needs across different age groups and risk factors, as detailed in the following table.

Preventive Service
Category of People

One-time screening for abdominal aortic aneurysm

Men of certain ages who have smoked

Screening and counseling for alcohol misuse

All adults

Aspirin use for cardiovascular and colorectal cancer prevention

Adults 50-59 with high cardiovascular risk

General blood pressure screening

All adults

Cholesterol checks for specific age groups or risks

Adults of specific ages or higher risk

Preventive Services for Women

Preventive services for women range from reproductive health to cancer screenings and general wellness.

Preventive Service
Affected Category of Women

Support and counseling for breastfeeding

Pregnant and nursing women

Contraceptive methods and education

Women capable of reproduction

Folic acid supplement provision

Women considering pregnancy

Screening for gestational diabetes

Women in later stages of pregnancy or high-risk

Higher risk gonorrhea screening

Women identified as higher risk

Preventive Services for Children

Preventive services for children cover a variety of health checks and interventions, vital for early detection, prevention and management of various health issues from birth through adolescence.

Preventive Service
Affected Age Group

Assessments for substance use


Autism screening

18 and 24 months

Behavioral evaluations

0 to 17 years

Newborn bilirubin screening


Blood pressure checks

0 to 17 years


Prescription drug coverage is standard in most health insurance plans, but the specific medications covered can vary significantly between insurers. Each plan maintains its own formulary — a comprehensive list of approved medications. To understand which drugs are covered under your plan, you can access this formulary on the insurer's website by contacting them directly or through the documentation they provide.


Formularies are categorized into tiers, influencing out-of-pocket costs. Typically, generic drugs are in lower tiers and cost less, while brand-name drugs are in higher tiers. When a required medication isn't in your plan's formulary, you can request an exception, especially if no alternative on the list effectively treats your condition.

Insurers may also implement prior authorization for certain drugs, requiring doctors to justify the need for specific medications. Step therapy might be another consideration, where you might be required to try more cost-effective drugs before progressing to more expensive options.

Doctor Visits and Hospital Stays

Health insurance plans generally cover consultations with primary care physicians, specialists and various medical providers. This includes a broad range of services, from routine doctor visits to specialized care. Hospital-related expenses, including emergency services, surgeries, outpatient procedures and inpatient hospital stays, are also typically covered.

Consider staying within your plan's network, which usually means lower costs. You should also know about the cost-sharing structure of your plan, which includes deductibles, copayments and co-insurance. You are responsible for most costs until your plan's deductible is met, after which you will start paying co-insurance, which means you split the cost with the insurance company based on the structure of your plan.

Moreover, some plans may require referrals or prior authorization for certain services or specialist visits.

Pre-Existing Conditions

Thanks to the Affordable Care Act, health insurers cannot refuse coverage or charge additional premiums based on pre-existing conditions. This applies to all ACA-compliant plans, ensuring equal access to health insurance for individuals with any health history. This policy protects those with chronic or past medical issues from financial penalties related to their health conditions.

What Health Insurance Does Not Cover

Health insurance typically covers a wide range of medical services, but certain services and procedures are usually excluded, including cosmetic procedures, fertility treatments, off-label prescriptions and experimental treatments. Some of the common benefits that health insurance does not cover include:

Cosmetic Procedures

Procedures aimed at enhancing appearance, like plastic surgery and some dermatological treatments, are generally not covered. These elective procedures offer price transparency due to consumer-driven demand.

Fertility Treatments

Coverage for fertility treatments varies significantly. While insurers are required to cover diagnostic testing for infertility, the treatment costs are often not covered. Coverage mandates differ by state, and employer-sponsored plans, especially self-insured ones, might not include fertility treatments.

Off-Label Prescriptions

Insurance may not cover prescription drugs used for conditions other than those they are FDA-approved for ("off-label" use). Although doctors can sometimes advocate for off-label coverage with supporting research, insurers are not obliged to cover these prescriptions.

New Medical Technologies

Coverage for new drugs, products or medical advancements is typically cautious. Insurers, including Medicare, often wait for substantial evidence of effectiveness and cost-benefit before including new technologies in their covered services.

Long-Term Care and Custodial Care

Most health insurance plans do not cover long-term care services, including extended nursing home stays or custodial care. Separate long-term care insurance is available for this purpose.

Alternative Therapies

Treatments like acupuncture, homeopathy or other alternative therapies are typically not covered unless specifically included in a plan.

Private Room and Non-essential Services

If hospitalized, costs for a private room or non-essential services are generally not covered.

Adult Dental and Vision Care

Routine dental and vision care for adults are often not included, requiring additional coverage.

How to Find Out What Your Health Insurance Covers

To find out what your health insurance covers, start by accessing the right resources and understanding key aspects of your plan so you can get a clear picture of your coverage. If you require further clarifications, contact the insurer.

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    Access and Review Your Summary of Benefits and Coverage (SBC)

    Obtain your plan’s Summary of Benefits and Coverage (SBC) from your insurance provider. This essential document, required for all plans, details covered services and associated costs. Complement this by exploring your insurer's online resources for additional plan specifics.

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    Confirm Network Providers and Prescription Coverage

    Ensure your preferred doctors, specialists and clinics are within your plan's network. Confirm if your essential prescriptions are covered and note any requirements for pre-authorizations. Choose the most affordable plans that cover your requirements.

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    Know Your Cost-Sharing Obligations

    Familiarize yourself with how copayments, deductibles and co-insurance affect your expenses. These terms define your share of costs for covered services.

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    Ask for Clarification When Needed

    If there are uncertainties or specific questions about your coverage, don’t hesitate to contact your insurer’s customer service. For employer-sponsored insurance, your HR department can also be a helpful resource.

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    Stay Informed on Plan Updates

    Regularly review your plan for any changes, particularly during renewal or open enrollment periods, to ensure continuous alignment with your health care needs.

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