Does health insurance cover anything besides doctors and medicine?

What is covered by health insurance?

Not knowing what’s covered can cost you—literally. That’s why it’s essential to understand your plan’s benefits before you need them. Most health insurance covers much more than the costs of doctor’s appointments and prescription medications.

As you know, health care goes far beyond a simple visit to the doctor or a prescription medication from a pharmacy. In our modern health care system, there are hundreds of care options, and widely varying treatments, medications, and therapies.

So, how do you know what’s covered and what’s not?

It’s important that you are aware of what is included in your plan so that you can make good decisions as far as your health and finances. If not, you could end up missing out on treatments or care that you need, or paying out of pocket for expensive care.

Here’s how to better understand what your health plan covers so that you can get the most out of your health insurance and so that you can easily navigate your health care in a way that is financially responsible and effective.

What coverage do you need?

The catch-22 of health care is that most people don’t know what coverage they need when they’re choosing a health plan. For example, imagine that you fall and badly break your leg. That injury requires ambulance services, an ER visit, an emergency surgery, prescription medication to prevent infection, several follow-up appointments, and months of physical therapy. Ouch!

Obviously, when you signed up for your health plan, you didn’t know that injury would take place, so you weren’t aware to make sure your health plan covered things like emergency surgery or ambulance rides or physical therapy.

There is good news: Most health insurance plans do cover most traditionally recommended and prescribed therapies. So in the example above, most plans would cover the emergency room visit, and the surgery, and the prescription medication, and the follow up visits.

The co-pays and deductibles and out of patient costs may vary, but for the most part, proven therapies used for common illnesses and injuries will be covered. For example, the vast majority of health plans have coverage for things like:

• Lab testing and evaluation
• Emergency medical care
• Mental health services
• Physical therapy
• Occupational therapy
• Speech therapy
• Prescribed medical devices

Our advice as you look at a health plan is to assume you could need the aforementioned therapies or care and to look for plans that have broad coverage with low out-of-pocket costs in those areas.

Less-typical covered services

Today’s family caregivers need more than checkups and prescriptions. Health plans are beginning to recognize this, covering services like care navigation and virtual support that make a real difference in managing care.

In addition to doctor’s visits and prescriptions and the services listed above, many health plans now cover less-typical but equally important services. Many of these services weren’t part of standard health care in the decades past, but because health plans discovered that by investing in this type of care the overall health of their members improved, they found that these services were worth the investment.

An example of this is Grayce. Grayce care navigation services actually save many employers and health plans money as members are able to discern the care they need for their loved ones, and seek out appropriate care as health issues pop up. This leads to huge time and cost savings. Some less-typical covered services include:

• Care navigation
• Wellness services
• Virtual on-call support
• Virtual centers of excellence
• AI-health care support
• Companion care
• Fertility care
• Ambulance or medical transport services

While plans coverage of the above services can vary, it’s a good idea to look into what your plan covers as the aforementioned services can be a huge bolster to your health care regimen, and can help you to manage your care in a more effective and efficient way.

Services that are generally not covered

There are some services, medications and treatments that are generally not covered by most health insurance. For example, most prescription drugs are approved to treat certain illnesses or disorders. If you want to use that drug for another purpose, then it may not be covered. Likewise, anything that’s cosmetic is often not covered. The following treatments and services are generally not part of most health plans:

• Cosmetic procedures
• Off-label prescriptions
• Medical equipment
• New exploratory treatments
• Wellness treatments like cryotherapy or airrosti

If you and your health care provider feel like one of these typical uncovered therapies could be helpful, know that exceptions can be made. Getting an exception can be a process–it often requires special documentation from your provider as to why such procedures, medications, or equipment may be necessary. Still, don’t be discouraged if you initially hear something vital will not be covered, because many health plans look to their members and participating health care providers to let them know how to expand their coverage.

Health insurance for complex care

If you or a loved one has a more complex health situation– such as the horrible leg injury we talked about earlier, or a diagnosis like cancer or diabetes– you may find yourself needing much more from your insurance company.

In this case, the first step would be to look into what your plan does cover– find out if your plan covers specific treatments or care that you need. Your next step is it reach out to your health care provider to let them know what isn’t covered, and find out if there are covered alternatives. Finally, you should call your plan and explain the situation, as they will likely work with you to get the care you need.

Figuring out what your plan covers

While most plans will have a summarized version of coverage on their website, if you have questions about the specific benefits covered by your plan, it is best to contact your insurance provider directly to inquire about coverage for treatments or care not specified in your policy information.

Whether you are shopping for the best health insurance policy to meet your needs, or trying to navigate existing coverage, your Grayce Care Partner is here to help. Your Care Partner can help you to understand what’s covered, help you to compare plans and benefits, and even assist with billing-related matters, with consent to speak to third-party providers on your behalf.