A health insurance plan covers some or all of a person’s medical expenses in exchange for a monthly premium. But what’s covered varies widely from one health insurer to another.
To get the best value, look at cost and benefits. Consider things like deductibles, copays and coinsurance. Also look at plan type — HMOs typically have lower costs while PPOs and EPOs offer more flexibility.
Coverage for Preexisting Conditions
Before the ACA (Obamacare) was passed, health insurance companies could exclude certain conditions or charge higher premiums for individuals with preexisting medical problems. This often meant that people with chronic diseases, like arthritis, asthma or depression, were unable to find affordable coverage for their condition. The ACA made it illegal for health insurance companies to deny coverage or impose waiting periods for preexisting conditions, as long as the person had not been uninsured for more than two years prior to enrolling in their plan.
The ACA also made it illegal for health insurance companies to increase premiums on the basis of a person’s health status or health history. This was known as “health status rating.” For example, a 48-year-old freelance writer named Lori obtained individual health insurance coverage after she lost her job and became unemployed. She was diagnosed with high blood pressure and had been taking medication to treat the condition. However, the only health insurance she could obtain in the individual market had a 12-month exclusion period for her hypertension.
Thankfully, these rules have now changed for people who buy their own health insurance in the individual market, or through the small business marketplace at eHealth. Aside from evaluating a company’s financial strength and customer satisfaction ratings, it is essential for consumers to review the specific coverage available for preexisting conditions in any health insurance policy they are considering.
This includes the extent to which a company will cover medications for a particular disease or illness, as well as the cost of any required procedures. It is also important to check the network size of a health insurance plan, as this can greatly impact the level of coverage and costs for medical care.
For example, UnitedHealthcare offers a very extensive network of doctors and hospitals, while Blue Cross Blue Shield (BCBS) has the highest financial strength rating of all of the major health insurers and is the top choice for many consumers looking for a broad selection of providers. However, there are also many plans in the individual market that offer a narrower network of preferred providers, such as HMOs (health maintenance organizations) or EPOs (exclusive provider organization). In these cases, it is essential to understand a company’s network options and compare them with those of your preferred health care providers.
Coverage for Mental Health Issues
Many health insurance companies include coverage for mental illness in their overall plans, but the specifics vary. Some provide reimbursement for therapy, medical management services or psychological testing services. Others offer telehealth or other online tools for managing mental health. Check your “summary of benefits and coverage” (SBC), which is typically sent to you when you enroll in a plan or can be found on the insurer’s website, for details.
For many patients, the best health insurance for mental health is the plan offered through their employer. Typically, these plans have a nationwide network of providers that is more extensive than what you’ll find in the individual or small business markets. For example, Aetna, one of the largest providers in our ratings, offers its members access to a full range of resources and programs that include a mental health focus. It also provides a telehealth service that allows members to talk with a counselor by phone, on video or in person about any work or family issues.
Another option is to enroll in a Medicare Advantage plan, which typically includes coverage for behavioral health treatment. While these plans don’t cover psychiatric hospitalization, they do provide coverage for outpatient visits and prescription medications to treat various conditions. However, Medicare Advantage plans can sometimes require referrals to see a psychiatrist or therapist.
While many people with health insurance through work or the ACA marketplace receive treatment for mental health problems, cost remains an issue. According to a recent Kaiser Family Foundation survey, about 33% of people who didn’t seek care said they couldn’t afford it. For those without insurance, that figure rose to 60%.
Other barriers to care are the lack of coordination between different types of providers, limited access to facilities and specialists and misaligned payment incentives. The enactment of the MHCA 2017 may help to alleviate these obstacles in the future, as it requires insurance companies to treat mental health issues at parity with physical illness. That, in turn, could lead to more efficient and effective treatment. The demand for more accessible health support is urgent, but the industry has a long way to go before it catches up to what patients need and deserve.
Coverage for Cancer Treatment
No one wants to think about a diagnosis of cancer, but it’s essential to do your research so that you know what kind of medical treatment you need. Many ACA-compliant health insurance plans provide extensive coverage for cancer diagnosis and treatments. But if you’re worried about the costs of treatment or have a family history of certain types of cancer, an additional cancer insurance policy may be worth the investment.
A cancer policy helps cover out-of-pocket expenses like deductibles, copays, experimental drugs and treatment and travel costs to receive treatment. While the specifics of your policy vary, some cancer insurance policies offer a lump sum payment or help you pay for individual expenses. Aflac’s comprehensive policy is a good example of a lump sum plan and provides coverage for cancer-related costs that many other health insurance policies don’t, such as an initial diagnosis benefit, anesthesia for surgical port placement, chemotherapy and blood/plasma benefits.
Some supplemental health insurance policies include coverage for travel expenses, lodging and meals if you have to leave home to get specialized care. CareSource offers this coverage as part of its marketplace health insurance plans in six states. This coverage is important for patients whose cancers require them to travel long distances for care.
If you’re on Medicare, make sure the health insurance plan you choose covers visits to doctors and hospitals in your region. Some Medicare Advantage plans, which combine Medicare Parts A and B into a single plan, limit you to a network of doctors and specialists. This might not be a problem if you’re healthy, but if you develop a chronic condition such as cancer, limiting yourself to a small group of doctors could delay your treatment.
Many cancer patients require multiple medications, including chemotherapy and immunotherapy drugs. When choosing a health insurance plan, look for a plan that covers the most common cancer medicines. Some plans use a system called coinsurance, which means you pay a set percentage of the cost of your medications after meeting your health insurance deductible. For cancer medication, this can add up quickly. CareSource’s marketplace plans, for instance, cover eight popular brand-name cancer medicines and some generics even before you meet your deductible.
Coverage for Preventive Care
For more than ten years, the Affordable Care Act (ACA) has required private insurance plans to cover certain preventive services without charging patients a deductible or copayment. This coverage is meant to help identify medical issues earlier and manage them more effectively, and it has been shown to improve overall health and reduce costs.
Preventive care includes regular check-ups, vaccinations and screening tests. The specific services vary by age and gender, but they include annual physicals, cholesterol checks, blood pressure screening, breast cancer screening and cervical cancer screening for those at high risk. Additionally, the ACA requires that all plans offer HPV vaccines for those at high risk of contracting the virus.
The ACA also mandates that all Marketplace health insurance plans cover all recommended preventive care for adults. This includes well child visits, immunizations and screenings for behavioral and developmental disorders, fluoride supplements and certain genetic diseases. It also includes mammograms and Pap smears for women who are between 40 and 65, and Hepatitis B screening for those at high risk, including U.S.-born adults who were born in countries with 2% or more Hepatitis B prevalence and those who do not have adequate hepatitis B vaccinations as children.
All plans must cover these recommended preventive services without charging a deductible or copayment. However, patients should be aware of the difference between preventive and diagnostic care. In some cases, a preventive service may reveal an abnormal result and require follow-up testing or treatment, which will then be considered diagnostic. For example, if your annual check-up uncovers something unusual on your blood work or your skin, it will quickly move from being considered preventive to diagnostic.
If you’re looking for a plan that covers preventive care, make sure you choose a Preferred Provider Organization (PPO) or Exclusive Provider Organization (EPO) plan. These types of plans typically have lower monthly premiums and allow you to choose your own doctors, while HMOs often charge higher monthly rates but limit you to choosing doctors within their network. Regardless of the type of plan you choose, it’s important to always check your coverage before getting any medical care.