Knowledge is power: What does my Health Insurance cover?

Q: What are “covered services”?

A: Basically, “covered services” are services such as tests, drugs, and treatment services that your insurance company agrees to pay in terms of certain benefits listed in your health policy.  On the other hand, your health policy also includes services that are not covered by your insurance company.  Hence, you pay on your own for uncovered services.

Q: What is the difference between a medical necessity and a covered service?

A: Simply, a medical necessity is something that your doctor has decided necessary.  In contrast, a medical benefit is something that your insurance plan has agreed to cover.  In particular, health insurance companies chooses the types of drugs or services they would cover with a clear understanding of the kinds of medical care most patients need.

Q: How can my physician provide me with the covered care that I need?

A: With many different health plans and what they are about, it is best to do and remember the following:

  • Thoroughly read and understand your insurance policy.
  • When in doubt, call and ask questions with your insurance company representative.
  • Your insurance company makes the decisions about what will be paid for, and what will not.

Q: What happens if my doctor recommends care that is not covered by my insurance?

A: Mostly, what your doctor recommends would be covered by your plan, however, some may not.  As an example, when you have a test that is not covered, or you get a prescription filled for a drug that is not covered, your insurance company won’t pay the bill.  Always consult with your doctor for the best plan of action.

Credit Source: Academy of Family Physicians, 12/09.

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