What Does a Health Benefit Plan Cover?

Health benefit plans provide coverage for a wide range of medical services, including inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, and more. Plans must also offer dental coverage for children. Most private sector health plans are covered by the Employee Retirement Income Security Act (ERISA). This law provides protection to participants and beneficiaries of employee benefit plans (participant rights), including access to plan information.

In addition, people who administer plans (and other fiduciaries) must comply with certain standards of conduct under the fiduciary responsibilities specified in the law.If a service is covered, it means that your health plan will pay part or all of the cost. In most cases, the doctor should also be on the list of doctors who take out your insurance, which is called a network. How much your health plan pays depends on the type of care you use and where you get it.The amount of money you pay for covered health care services before your health insurance starts paying the bill is known as a deductible. If your cost exceeds the deductible, your plan will cover the rest or a percentage of the rest.

If you're in the process of choosing a health insurance plan, it's helpful to know that plans with higher deductibles tend to have lower premiums. The amount you pay for a health care service to providers who have a contract with your health insurance company is an in-network co-pay.This type of health care coverage is generally offered through an employer, giving employees the opportunity to select from different health benefit options that best fit their financial and medical needs. Care coordination involves the exchange of information between different healthcare providers (primary care doctors, your health insurance company, etc.).A built-in deductible is when individual members of a family health plan only need to cover their own deductible before the health insurance company reimburses service charges. Routine medical care that includes screenings, checkups, and counseling for patients to prevent diseases, illnesses, or other health problems is known as preventive care.

Check your insurance policy to see if you can go to all the providers that have a contract with your health plan, or if your health plan has a “tiered network” where you must pay more to see certain providers.The centers, providers and medical providers that your health insurance company has contracted with to provide health care services are known as in-network providers. An out-of-network co-pay is the amount you pay for a health care service to a provider who doesn't have a contract with your health insurance company. Out-of-network coinsurance is the percentage you pay for covered health care services to providers who don't have a contract with your health insurance company.If you are in a situation where you need ongoing medical assistance, a doctor may admit you to a hospital, nursing facility, or other facility in the health care program. Once you've met your deductible, in-network coinsurance is the percentage of a health care service you pay to a doctor contracted by your health insurance plan.

To control costs, your health plan can create what's called a network of preferred providers (or in-network providers), which can include doctors, hospitals, pharmacies, and other healthcare providers, where you pay less out of pocket.

Gertraude Jackel
Gertraude Jackel

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