Health Insurance Benefits 101

Image of an X-ray of someone's hand doing the OK sign. Hopefully, this is covered by their health insurance benefits.
Photo by Owen Beard on Unsplash.

Everyone hears about health insurance benefits at work, but what even are those? Can you just go to the doctor every day for nothing? Oh! Are you able to get plastic surgery? These are the kinds of things that need to be clarified in any health insurance policy so let’s take a look at what’s likely to be in your benefits package.

What’s Covered By Health Insurance Benefits?

Now, this is wholly depended on your specific plan, but there are a few key things to look for in your policy.

  1. Preventive care: This covers things like vaccinations, screenings (e.g. mammograms, colonoscopies, etc.), and general check-ups. Typically, your insurance will cover these 100% with zero out-of-pocket cost. So go get checked!
  2. Primary care visits: Visits to your primary care doctor fall under this banner. Whether for a check-up or diagnosis and treatment of common illnesses and injures, these visits can be fully covered, but are likely to come with a co-pay of some sort.
  3. Prescription drugs: Most health insurance benefits will cover a pretty wide range of prescriptions. Your out-of-pocket cost can vary depending on the type of drug, so make sure you understand what your responsibility is before you get to the counter.
  4. Specialist care: If you need to be referred to/see a specialist (cardiologist, dermatologist, etc.) it will be covered by specialist care. Things can be a bit more costly here and your deductible will come in to play when seeing these providers.
  5. Hospitalization and emergency care: This will cover ER visits (may they be minimal at best) and longer stay hospital stays. The cost of your room and board, nursing care, and any procedures needed (e.g. surgery), like specialist care, will depend on your deductible when you get treatment. Co-pay/coinsurance will also affect your out-of-pocket cost here.
  6. Lab and diagnostic tests: Blood work, X-rays, MRIs, etc. are all covered under lab and diagnostics. You’ve probably noticed the pattern since we hit specialist care. That’s right, your deductible will greatly affect your out-of-pocket cost here and you’re likely to have some type of co-pay/coinsurance cost regardless.
  7. Maternity and newborn care: Prenatal care, childbirth, and general care for your newborn are included here. Being one of the most expensive procedures in medicine, it will be more important than ever to note your deductible, co-pay/coinsurance, and just how much you will be responsible for out of pocket.
  8. Mental health and substance abuse treatment: Covers therapy, counseling, and inpatient/outpatient treatment. All insurance policies cover both mental health and substance abuse, but be sure you’re aware how much is covered.
  9. Rehabilitative and habilitative services: If covered by your insurance, this will include physical therapy, occupational therapy, speech therapy, etc. There may be co-pays necessary per session, so keep that in mind.
  10. Durable medical equipment (DME): Finally, your health insurance benefits may cover things like wheelchairs, crutches, oxygen equipment, etc. Whether you suffer from short-term or long-term disabilities/conditions, this may be key to your health and functionality.

Understanding your plan is BEYOND necessary. Things like deductibles, co-pays/coinsurance, out-of-pocket maximums, and network restrictions can all impact how much you spend year to year. Take the time to review your policy or seek assistance from your HR department/call the insurance company directly for clarification on anything you’re not clear on.

What Are Possible Limitations/Restrictions?

GIF of a Key & Peele skit where one has to explain to their partner that not everything is covered by their health insurance benefits.

Just as important as knowing what is covered is knowing what is not. Of course, something that’s not covered by your insurance is 100% coming out of your pocket. You see the issue here.

  1. Exclusions: Certain types of treatments, procedures, or services may be outright excluded from being covered. Cosmetic surgery or experimental treatments will likely fall under these exclusions.
  2. Specific treatment limits: Your policy may limit how many times you can get a treatment or service within a certain period of time. For instance, you may only be able to go to physical therapy once a week during a calendar year.
  3. Annual/lifetime maximums: This one is major. Your policy may limit the max amount they will pay out for certain types of care throughout the year or over the lifetime of the policy. Once you hit that cap, any future services will have to be paid out of pocket.
  4. Network restrictions: Your health insurance benefits may not cover every health provider you see. If you stay within their defined network, you’re good. However, if you go out-of-network, you’ll likely be hit with higher fees or limited coverage.
  5. Geographic limitations: Some policies will only cover you in certain places. In other words, your insurance may work great here, but it may not cover you when you travel out of the country.
  6. Waiting periods: There is a chance your policy won’t be active immediately. Plan accordingly so you don’t jump the gun and book an appointment before you’re actually covered.
  7. Age limits: There are certain policy points that are age restricted. For instance, once you’re 26, normally, you can no longer be covered under your parent’s insurance.
  8. Experimental or investigational treatments: If procedures or treatments are deemed experimental, investigational, or simply not medically necessary, they may not be covered. Be sure to check in with your company before you’re left holding the bag after a costly procedure.

Again, always stay informed. Contact your HR department/your insurance company for clarification on anything you don’t fully understand. Your health and finances are worth more than a few “silly” questions.

What Are Considered Additional Benefits?

These are usually the perks that separate good health insurance benefits from great health insurance benefits. If you have access to these perks, know that you’re doing well.

  1. Dental insurance: You’ll typically be covered for preventive care (cleanings, check-ups, etc.), basic procedures (fillings, extractions, etc.), and major procedures (root canals, crowns, etc. 🫢). Though there will be co-payments/coinsurance, having dental insurance makes taking care of your teeth far more affordable than it would be otherwise.
  2. Vision insurance: Here we cover eye exams, prescription eyewear (glasses/contacts), and might even include discounts on procedures like LASIK. Again, you’ll likely have co-pays/coinsurance to cover, but it can lessen the impact to your wallet quite a bit.
  3. Pet insurance: That’s right, your fur baby can be covered too! Pet insurance is becoming more common these days and essentially covers your pet with the vet the way your insurance covers you with doctors.
GIF of a dog petting their human as they lie on the bed, showing his appreciation for the health insurance benefits his owner has that includes pet insurance.
You take care of them, they take care of you, and the love goes ’round and ’round.

Bonus Round: Supplemental Health Insurance Benefits

Supplemental health insurance benefits give you just a bit more cushion between you and your medical costs.

  • Long-term care insurance: This helps cover the costs for chronic illnesses, disabilities, and the like. Nursing homes, assisted living facilities, and in-home care all fall under this umbrella.
  • Critical illness insurance: Here, you’ll receive a lump-sum payment if diagnosed with a serious illness like cancer, heart attack, or stroke.
  • Accident insurance: Provides benefits to cover you in case of an accident. This can include payments for hospital stays, ER visits, and other related costs.
  • Cancer insurance: Used specifically to help curb the insane costs of cancer treatments including chemotherapy, radiation, surgeries, and medications.
  • Hospital indemnity insurance: This is basically a payment for each day you’re in the hospital. It’s used to offset the cost of your stay.
  • Disability insurance: Provides income replacement if you can no longer work due to illness or injury. It is really helpful for covering everyday expenses and ongoing medical costs.

The Wrap Up

Yes, there is a lot here. Don’t let that intimidate you! What you have here are options. All you need to do is take what you need and leave what you don’t. As mentioned earlier, contact your HR department/insurance company to ask any questions you may have. You’re paying for it, there’s no reason you shouldn’t fully understand your insurance. Stay covered and stay healthy!

Headshot picture of the writer of this article, Kenneth Medford III, with a muted black and white filter.
Kenneth Medford III

Writer, rhymer, gamer: the easiest way to define the man known as Kenneth Medford. I’m a simple man who loves to learn and loves to help and I wander the digital world trying to find ways to sate my hunger for both. Basically, I’m Galactus but helpful.

Check out my other work here or reach out to me on LinkedIn.

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