How to Get a Handle on What Your Health Insurance Actually Covers

How to Get a Handle on What Your Health Insurance Actually Covers

1000 667 Jennifer Nelson

You outsmarted your calendar this year, circled the open enrollment deadline and nabbed what you think is pretty good health insurance coverage. Now, where exactly do you find out the specifics of what your plan covers? Before you schedule a physical or book that dermatology appointment, here are some simple tips for getting to the bottom of your policy.

Why It’s Important to Understand Your Health Insurance Coverage

You can probably guess what happens to folks who don’t know what their policy covers: Think large, unexpected medical bills, denials at the doctor’s office and paying out-of-pocket at the pharmacy for brand-name prescriptions that aren’t covered, to name a few.

Where to Look to Find Your Health Insurance Coverage Specifics

Because health insurance plans are written with legal language and a lot of medical jargon, they can be hard to decipher. Most policies list the preventive benefits covered at no cost to you front and center. These may be labeled the “10 essential health benefits” and will include shots, some health screenings, lab services and prescription drugs. Review the list thoroughly.

Here’s a quick rundown of some of the other useful sections you might find in your policy.

  • Definition. This section will define any words you’re not familiar with.
  • Explanation of benefits. This is a long list of what your policy pays a percentage of.
  • Formulary. This lists the prescription drugs the policy covers.
  • Preauthorization. This section covers all the medical treatments you need prior approval for, such as surgery.
  • Exclusions. This is what’s not covered. Here you may find things like alternative therapies, fertility treatments and private rooms.

Of course, you’ll see information about your copays for various services as well as your deductible, out-of-pocket limits, what type of plan you have (HMO or PPO, for instance), the plan year and your plan’s administrator.

You also may find a summary plan description that acts as an overview or declarations page of your policy. While this is a convenient overview, it’s still is only a summary, so it’s not the best spot to look for a specific covered service.

If all this still sounds like a lot to wade through, think outside the box — or off the page. If you bought your plan through a broker, consider turning to them for answers. If you got it through your employer, check in with HR to see if they can help unpack it for you. Your insurance company can give you information beyond what’s written in your policy, too. Check their website for helpful articles or FAQ-style answers in plain English. And don’t be shy about getting in touch with your insurance company to ask questions — that’s what their customer service department is there for.

What to Do If You Find Gaps in Your Coverage

A lot of what your doctor recommends will be covered at least partially by your primary health insurance, but sometimes you’ll come up against a service or treatment that isn’t included. Look for these gaps ahead of time to save yourself the headache of paying out of pocket for something you didn’t expect.

When you find a gap, talk to your doctor and insurance company about how you can cover it. You may find that by adding a supplemental insurance plan, you’ll have coverage for some of the extra costs that might come with an unexpected accident, injury or trip to the hospital. If “peace of mind” wasn’t listed on your policy, a supplemental plan can help provide it.

Knowing what your plan covers will take a thorough look through your policy and any addendums it has, plus the occasional phone call when you really can’t find the information you’re searching for. It’s a bit of work, sure, but it can save you the horror of the receptionist telling you that your visit won’t be covered — or, possibly worse, the shock of getting a mega bill in the mail after the fact. Make sure you know what your insurance will pay before you’re in the ER getting an X-ray or asking your OB-GYN for that brand-name birth control.

Jennifer Nelson

Jennifer Nelson is an award winning health, health IT, and personal finance writer.

All stories by:Jennifer Nelson

Jennifer Nelson

Jennifer Nelson is an award winning health, health IT, and personal finance writer.

All stories by:Jennifer Nelson