Do You Know What Your Health Insurance Covers?

One the most frequently asked questions we get at our Smart Choice / Smart Use Health Insurance™ trainings is, “How do I know which insurance plan to choose?” You may have wondered this exact question during open enrollment last fall. You may be asking it right now if you’re starting a new job or experiencing other life changes, like adding a spouse or child on to your plan or turning 26. To answer this question you need to know what the insurance plan covers.

Before the Affordable Care Act, comparing plans was more difficult. You had to review the Evidence of Coverage and Benefits, which is a document provided by the insurer that details what the plan does or does not cover, and which services may be limited. Now, you can just compare the ten Essential Health Benefits that all Marketplace plans, and most non-Marketplace plans, incorporate. These benefits ensure that you receive a minimum of services on health insurance plans.

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Was your flu shot free this year? If not, you may want to review and compare plans during Open Enrollment. Most plans offer the flu shot for free. (Photo by Hyttalo Souza)

Once you select a plan, it is important you know which Essential Health Benefits you are paying for and how to use them. Maximizing on your benefits keeps you healthy, prevents illness, and saves you money.

What services do Essential Health Benefits cover?

Preventive and Wellness Services: Health care that includes screenings, check-ups, and patient counseling to help prevent illness or other health problems.

Prescription Drugs: A list of prescription drugs that are fully or partially paid by your health plan.

Laboratory Services: Testing needed for diagnoses, preventative screenings, and monitoring.

Pregnancy, Maternity, and Newborn Care: Covers outpatient and inpatient services for pregnancy, maternity, and newborn care.

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Preventative care for infants can require several well-child visits in the first few years of life, which include vaccinations and possible screenings. If you know that you’ll be having a baby, make sure to compare co-payments or co-insurance for different plans. While all marketplace plans cover these costs as preventative care, some employer-offered plans may not. (Photo by Kelly Sikkema)

Pediatric Services: Preventive services for children, including annual visits until the child turns 21.

Mental Health and Substance Use Disorder Services: Health care to manage mood, feelings, behaviors, and substance abuse.

Ambulatory Services: When you receive care in a hospital or other health care facility and leave the same day. Also called outpatient services.

Emergency Services: Any health care service that checks or treats an emergency medical condition.

Hospitalization: When you receive care in a hospital or other health care facility and stay overnight. Also called inpatient services.

Rehabilitative and Habilitative Services: Services that help you keep, recover, learn or improve skills and activities for daily living that have been lost or limited due to illness, injury, or disability.

Some of these services are free, such as annual check-ups, while others may include costs that count towards your deductible, or have co-payments or co-insurance. These services can serve as the foundation for comparing health plans. If you are not purchasing from the Marketplace, make sure your plan includes these benefits. When selecting a plan, remember to compare the co-payment or co-insurance for these services.

If you want to learn more, join us in-person or online for one of our Smart Choice or Smart Use Health Insurance seminars. You can contact me at for more details.

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