What Does Health Insurance Cover? What’s Included vs What’s Not

Life & Health

What Does Health Insurance Cover? (What’s Included vs What’s Not)

If you’ve ever stared at your Health insurance plan like it’s written in ancient Greek… you are definitely not alone.

Most people think they know what Health insurance covers – until they get a bill for $847 and suddenly realize: “Wait… I thought this was covered??”

So let’s break it down the normal-person way:

  • What Health insurance usually covers
  • What Health insurance often does NOT cover
  • Common surprises that cause big bills
  • And the most important tip: check your Summary of Benefits and Coverage (SBC)

(Yes, it’s a boring document. But it’s the one that saves you from expensive surprises.)

By the way, if you are still shopping for coverage, you’ll also want to read PPO vs HMO vs EPO: How to Choose a Health Insurance Plan (it helps you pick the right setup before you commit).

What does Health insurance cover? (The basics)

Most Health insurance plans cover a similar “core menu” of services, but the price you pay depends on your plan details.

Just because something is “covered” doesn’t always mean it’s “free.”

Not sure why your plan still makes you pay? This breakdown helps: Deductible vs Copay vs Coinsurance: What’s the Difference in Health Insurance?

Here’s what’s typically included:

1) Preventive care (usually covered at $0)

This is one of the best parts of Health insurance – preventive care is often covered at no cost to you as long as you go in-network.

Preventive care usually includes:

  • Annual physical / wellness visit
  • Screenings (blood pressure, cholesterol, diabetes, etc.)
  • Mammograms (based on age guidelines)
  • Colon cancer screenings (based on age guidelines)
  • Vaccines (flu shot, etc.)
  • Well-woman visits
  • Certain birth control options (varies by plan)

Important: Preventive care is not the same as “anything you do at your yearly appointment.”
If you go in for your annual exam and also talk about knee pain, migraines, or fatigue… that can turn into a regular office visit and get billed differently.

  • Preventive care: “routine checkup”
  • Problem visit: “I have symptoms.”

That’s where people get surprised.

2) Primary care visits (doctor’s office)

Most plans cover:

  • Primary care visits (your regular doctor)
  • Specialist visits (dermatologist, cardiologist, etc.)

But what you pay depends on your plan type:

  • Some plans use a copay (for example, $35 per visit)
  • Other plans make you pay full price until you meet your deductible
  • Some use coinsurance (for example, you pay 20% after the deductible).

So yes – the visit is covered… but the cost can vary wildly.

3) Urgent care (for “it can’t wait, but it’s not an emergency”)

Urgent care is usually covered, and it’s typically cheaper than the emergency room.

Good reasons for urgent care:

  • Fever / infection
  • Minor fractures
  • Strep throat
  • UTI symptoms
  • Sprains
  • Ear infections

Many plans have a copay for urgent care, like:

  • $50 urgent care copay
  • vs. $500+ emergency room bill

Urgent care is your friend.

4) Emergency room (ER)

Health insurance usually covers emergency room visits, but ER costs are often where people are most shocked.

Even when covered, you might pay:

  • An ER copay (for example, $250)
  • Plus deductible
  • Plus coinsurance

And here’s the tricky part:

ER bills can multiply fast

Because you are not just paying for the ER visit – you can also be billed for:

  • Facility fee (the hospital)
  • Doctor fee (the provider group)
  • Imaging (CT scan, X-ray)
  • Labs
  • Ambulance (sometimes… barely covered)

So yes, ER is covered, but it’s rarely cheap.

5) Prescriptions (medications)

Most Health insurance plans cover prescription drugs, but not all medications are treated equally.

Your plan usually has a “drug list” called a formulary.

Prescription coverage may include:

  • Generic meds (usually cheapest)
  • Brand-name meds (higher cost)
  • Specialty meds (highest cost)

Some people assume:

“My insurance covers prescriptions.”

And then they go pick one up, and it’s $400 because:

  • It’s not on the formulary
  • It requires prior authorization
  • It’s considered “non-preferred”
  • The deductible applies.

So prescriptions are covered, but the details matter.

6) Mental health coverage (therapy + psychiatry)

Most modern plans include mental health services like:

  • Therapy (counseling)
  • Psychiatry visits
  • Medications for anxiety/depression/ADHD, etc.
  • Substance use treatment (varies)

But here’s what surprises people:

  • Therapy can be covered
  • But you may still pay a copay or coinsurance
  • And many therapists are out-of-network.

So you’ll want to confirm:

  • Is the provider in-network?
  • Is therapy subject to a deductible?
  • Do you have visit limits?

What Health insurance often does NOT cover

Now we get into the part nobody wants to hear… but everybody needs to know.

Here are common things that may not be covered or may only be partially covered:

1) Out-of-network care (or it’s covered “badly”)

This is one of the biggest reasons people get huge bills.

Even if your plan covers out-of-network care, it may mean:

  • Higher deductible
  • Higher coinsurance
  • No protection from “balance billing”
  • You might have to submit claims yourself.

And some plan types (like many HMO and EPO plans) may cover zero out-of-network care unless it’s an emergency.

Out-of-network rules are among the biggest differences between plan types – especially between HMOs and EPOs. Here’s a quick guide: PPO vs HMO vs EPO.

Safe rule:
If you want predictable costs, stay in-network.

2) Imaging and scans (MRI, CT scans, ultrasounds)

This one surprises everyone.

People assume imaging is “just part of the visit,” but it often has its own billing and rules.

Imaging may be covered, but:

  • You might need prior authorization
  • You may have to pay the deductible first
  • The location matters (hospital imaging usually costs more than an independent imaging center)

Same scan… dramatically different bill.

3) Prior authorization (the “permission slip” problem)

Prior authorization means the insurance company wants proof that the service is medically necessary before they agree to cover it.

This commonly applies to:

  • MRI / CT scans
  • Certain medications
  • Sleep studies
  • Some surgeries or procedures
  • Specialty treatments

And here’s the frustrating part:

Even if your doctor orders it, the plan can still say:
“Not covered until we approve it.”

So if something is delayed or denied, it doesn’t always mean your doctor did something wrong. It’s usually just insurance being… insurance.

4) Cosmetic procedures (usually not covered)

Health insurance generally does not cover cosmetic procedures that aren’t medically necessary, like:

  • Cosmetic Botox
  • Teeth whitening
  • Cosmetic surgery
  • “Aesthetic” treatments

However, procedures can be covered if they are medically necessary (example: reconstruction after an accident).

5) Dental and vision (often separate)

Many standard Health insurance plans don’t include full dental and vision coverage for adults.

You might need separate plans for:

  • Dental cleanings, fillings, crowns, etc.
  • Vision exams, glasses, contacts

Some plans include limited perks, but they vary.

Common Health insurance surprises (aka “why is this bill so high?”)

Here are the biggest “wait WHAT?” moments that hit people:

Surprise #1: “My doctor was in-network, but the lab wasn’t”

You go to an in-network doctor, but your bloodwork is processed by an out-of-network lab.

Result: out-of-network bill.

Surprise #2: “The hospital was in-network, but the ER doctor wasn’t”

Some hospitals use third-party ER doctor groups.

So you may get separate bills.

Surprise #3: Imaging costs more than expected

An MRI might be covered, but you are responsible for the deductible and coinsurance.

Surprise #4: You thought a service was preventive… but it wasn’t

A physical is preventive.
But if you add a discussion of symptoms, it may be considered diagnostic billing.

The smartest move: check your Summary of Benefits (SBC)

If you do only ONE thing after reading this post, do this:

Find your Summary of Benefits and Coverage (SBC).

It’s a simple document that outlines what your plan covers and what you’ll pay for common services.

Look for sections like:

  • Primary care visit cost
  • Specialist visit cost
  • Urgent care and ER costs
  • Prescription tiers
  • Imaging (MRI/CT) coverage
  • Deductible and out-of-pocket max
  • In-network vs out-of-network rules

Our tip:
If your plan language feels confusing (because it can be), the SBC is the cleaner, easier version.

Quick cheat sheet: What’s included vs what’s not

Usually covered (but may cost you):

  • Preventive care
  • Doctor visits
  • Specialists
  • Urgent care
  • Emergency room
  • Prescriptions
  • Mental health care

Often not covered (or limited):

  • Cosmetic procedures
  • Out-of-network care (especially on HMO/EPO plans)
  • Some imaging without prior authorization
  • Some specialty medications without approval
  • Dental and vision (often separate)

Final thought

Health insurance does cover a lot – it’s not useless, but it’s not always straightforward.

And the biggest “gotcha” is this:

Covered does not always mean free.

If you want to avoid the random expensive surprises, your best move is:

  • Stay in-network
  • Know your deductible
  • Watch for imaging and out-of-network bills
  • And check your SBC before you assume anything.

Because nobody likes learning how their plan works after they get a bill.

Related Posts

Scroll to Top