What does health insurance cover?

Last year, I paid $30 for my flu shot. This year, I’ll pay nothing, as long as I go to my own clinic or one of dozens of others approved by my health insurance company. That’s one of the changes made by the Affordable Care Act (Obamacare).

The Affordable Care Act (Obamacare) requires insurance policies to cover ten basic areas:

• Outpatient care
• Emergency services
• Hospitalization
• Pregnancy, maternity, and newborn care
• Mental health and substance use disorder services
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric (children’s) services

For nine of the ten areas, insurance companies may charge deductibles, co-pays or co-insurance. In one area — preventive and wellness services — a list of specific items, including most immunizations, must be 100 percent covered, with no charge to you.

This is the one of a series of articles on understanding health insurance. Click here for all of the articles. This series covers basics — exceptions and complications go beyond the basics.

That’s where my flu shot comes in. It’s one of the free preventive services required by the Affordable Care Act. These services are free only if they are offered by a network provider. That’s a provider designated by the insurance company. My clinic is in-network. Target clinics are in-network. My pharmacy is not. As with all other services, I have to check with my insurance company to find out what providers are covered.

This Healthcare.gov page has a complete list of the required-to-be-free preventive services for all adults, which range from vaccinations to colonoscopies. Women’s free preventive services, listed on this page, include mammograms, gestational diabetes and anemia screening, birth control (see “Complications” below), and more. Children’s free preventive services include autism screening, behavioral assessments, immunizations and more.

What’s not covered

Dental care is not covered by all plans. Usually, you have to buy a separate plan for dental insurance. As with health insurance, dental insurance doesn’t cover everything. If you are buying dental insurance, check to see what it covers and what it does not cover.

Vision care is another exception. Some health plans cover eye exams and glasses. Others do not. Or it might cover eye exams, but not glasses.

Plans do cover some dental and vision care for children. Check each plan for details.

Complications

When it comes to insurance, nothing is simple. This series covers basics — exceptions and complications go beyond the basics.

One complication in the preventive care area: Health plans sponsored by certain exempt “religious employers” might not include birth control.

Another complication: Companies that self-insure do not have to offer the ten essential benefits. Some “grandfathered” plans do not have to offer them. These benefits apply to all plans offered through the insurance marketplace. Plans may offer more benefits, but must at least offer the essentials.

Articles in this series:

• Trouble ahead? Three health insurance alerts
• Open enrollment time: Should you renew or change your health insurance?
• Beyond the premium: What will you really pay for health care?
• Putting together the puzzle: Deductibles, copayments, co-insurance, out-of-pocket limit
• What you need to know about health insurance bills, networks and tiers
• What does health insurance cover?
• If you can’t afford health insurance … three ways to get help 
• Key questions: Choosing your family’s health insurance