✔ What’s Usually Included in Health Insurance
1. Preventive Care
Most plans cover preventive services at no cost when using in-network providers. This often includes:
- Annual checkups
- Vaccinations
- Screenings (blood pressure, cancer, cholesterol, etc.)
2. Doctor Visits (Primary & Specialist)
Office visits to general practitioners and specialists are typically covered, though you may pay a copay or coinsurance.
3. Emergency Care
Emergency room visits are covered, regardless of network, but often with higher out-of-pocket costs.
4. Hospitalization
Includes both planned surgeries and unplanned inpatient care:
- Room and board
- Surgery fees
- Inpatient medication
5. Prescription Drugs
Most plans cover medications through a tiered system, where generic drugs cost less than brand-name options.
6. Mental Health & Substance Abuse Treatment
Thanks to federal regulations (MHPAEA), mental health care must be covered similarly to physical health care.
7. Maternity & Newborn Care
Prenatal checkups, labor/delivery, and newborn screenings are typically included.
8. Lab Tests & Imaging
Blood tests, X-rays, MRIs, and other diagnostics are usually covered with cost-sharing.
✘ What’s Often NOT Included in Health Insurance
1. Cosmetic Procedures
Treatments done for appearance only—such as Botox, facelifts, or liposuction—are typically excluded.
2. Dental and Vision Care
Most standard health insurance plans do not include:
- Dental cleanings
- Fillings
- Braces
- Vision exams or glasses Separate dental/vision plans are required.
3. Infertility Treatments
IVF and other fertility services are often excluded or only partially covered, depending on your state.
4. Alternative or Complementary Therapies
Coverage varies, but many plans do NOT include:
- Acupuncture
- Massage therapy
- Chiropractic care (sometimes covered with limits)
5. Long-Term Care
Nursing homes, assisted living, and long-term assistance are usually not covered.
6. Over-the-Counter Medications
Pain relievers, cold medicine, or supplements usually aren’t covered unless prescribed.
7. Experimental or Investigational Treatments
Clinical trials or new technologies without proven effectiveness are often excluded.
How to Avoid Surprises
Here are simple tips to better understand your coverage:
✔ Review your Summary of Benefits and Coverage (SBC)
This document outlines deductibles, copays, coinsurance, and included services.
✔ Stay in-network when possible
Out-of-network care is often far more expensive.
✔ Check drug formularies
Make sure your regular prescriptions are covered under your plan’s medication list.
✔ Ask about preauthorization
Some procedures require approval before insurance will pay.
Bottom Line
Health insurance can save you thousands of dollars, but only when you understand what the plan includes and excludes. By reviewing your policy carefully and choosing the right coverage for your needs, you can avoid unexpected costs and ensure you’re protected when it matters most.