What is Health insurance?

The concept of health insurance revolves around the provision of coverage for medical expenses.

A contractual agreement is established between a health insurance company and the policyholder, wherein the insurance company commits to covering medical expenses that fall under the policyholder’s coverage, in return for regular premium payments.

According to Ryan Bullock, the chief operating officer of Aeroflow Healthcare, health insurance is specifically created to assist individuals in handling the expenses related to medical care.

Individuals without health insurance may choose to forgo seeking medical attention, even if they have health concerns, due to the exorbitant expenses they would have to pay out-of-pocket. Tarek El Ali, the creator of Smart Insurance Agents health insurance agency, asserts that health insurance acts as a protective measure against the substantial financial burdens associated with medical treatments, consultations, prescriptions, and hospital stays.

  • What expenses are typically included in health insurance coverage?
    These 10 essential benefits must be covered by all health insurance plans in the Health Insurance Marketplace, also known as the Marketplace, in accordance with the Affordable Care Act (ACA).


  • Outpatient care includes ambulatory patient services.
  • The provision of preventive and wellness services, along with the management of chronic diseases.
  • Services that are provided in times of emergencies.
  • The hospitalization process encompasses surgical procedures and extended stays.
    The provision of laboratory services.
  • Services pertaining to mental health, behavioral health, and substance use disorder are provided.
  • The range of pediatric services encompasses dental and vision care as well.
  • Coverage for pregnancy, maternity, newborn care, birth control, and breastfeeding is provided.
  • Medications that require a doctor’s prescription.
  • Devices and services that focus on rehabilitation and habilitation are essential for promoting recovery and development.

The services offered within these categories may differ based on the specific requirements of your state. Additionally, plans may include coverage for adult dental or vision care, as well as medical management programs that support plan members in managing conditions like back pain, diabetes, and weight.

The benefits provided by insurance companies can differ when it comes to various plans. To fully understand the coverage and limitations of each health insurance plan, it is crucial to carefully review the details.

Is dental care included in health insurance coverage?

For individuals under the age of 18, dental coverage is a necessary component of health insurance plans that comply with the Affordable Care Act (ACA). This implies that it must be included either within the health plan itself or offered as a separate dental plan. On the other hand, dental care for adults is not considered an essential benefit, which means that whether your health insurance covers dental expenses will depend on the specifics of your plan.

Certain healthcare plans offer dental coverage, combining both medical and dental expenses under a single premium. However, if your plan does not include dental coverage, you have the option to purchase separate dental insurance through the Marketplace. In this case, you will be responsible for paying a premium for your health insurance plan as well as an additional premium for your dental plan.

Within the Marketplace, individuals have the option to select from two distinct categories of dental insurance: low coverage and high coverage.

Opting for a low coverage plan entails higher copays and deductibles, but it also comes with the benefit of more affordable premiums.
Premiums for a high coverage plan may be more costly, but the trade-off is lower copays and deductibles.

Are there any medical expenses that health insurance does not include in its coverage?
Health insurance coverage can differ, as mentioned by Shashank Agarwal, a senior decision scientist at CVS Health. However, it is important to note that certain medical expenses may not be included in health insurance plans.

  • Acupuncture and chiropractic care are among the alternative therapies available for individuals seeking non-traditional treatment options.
  • Procedures that are cosmetic or elective in nature.
  • If dental or vision care is not included in your health plan, you may need to seek separate coverage for these services.
  • Innovative therapies.
  • Access to healthcare beyond the borders of the United States.
  • Medications that are not necessary or drugs that have not received approval from the FDA.
  • Medical services received from providers who are not within the network.
  • Bullock noted that your health plan could potentially have restrictions on fertility treatments, cutting-edge advancements, or the use of drugs for off-label purposes.
  • Additionally, limitations or exclusions may apply to pre-existing conditions, dental care, vision care, and long-term care.

Adam Rosenfeld, president of Rubicon Benefits, a division of World Insurance, cautions that while rehabilitative care is typically covered by most health insurance plans, developmental services may not be. While your insurance would cover physical therapy after knee surgery, speech therapy for a child with developmental delays may not be included.

Similar to how plan benefits can differ based on the level of coverage and insurance provider, policy exclusions can also vary. By comparing the specific details of plan benefits, particularly what is not covered, you can make an informed decision about which plan aligns best with your healthcare requirements.

What categories do health insurance plans fall into?

In the Marketplace, there exists a variety of health insurance plans, with each metal tier (Bronze, Silver, Gold, and Platinum) offering multiple options that may be available in your local area.

A health maintenance organization (HMO) is a cost-effective option for health insurance, although it restricts coverage to in-network providers unless there is an emergency. To access specialized care, you must first choose a primary care physician who can provide referrals. It may be necessary to reside or work within a specific proximity to the HMO’s service network in order to receive coverage.
Similar to an HMO, an EPO plan exclusively provides coverage for in-network healthcare services, except in emergency situations. However, unlike an HMO, you generally do not require a referral to consult with an in-network specialist under an EPO plan. EPOs typically offer a wider network of providers compared to HMOs, although the premiums associated with EPOs are usually higher. It is worth noting that EPOs are not as commonly available as other types of plans.

With point of service (POS) plans, you have access to a limited network of in-network healthcare providers. However, if you choose to receive care from an out-of-network provider, you will have to pay a higher cost. It is important to note that in order to see a specialist, you will need a referral from your primary care physician.
With preferred provider organization (PPO) plans, you have the option of receiving care from in-network providers. However, if you choose to go out-of-network, you will incur higher costs. There is no requirement for referrals or the selection of a primary care physician.
Discovering the ideal health insurance that suits your specific requirements can be a challenging task.
To discover the optimal medical insurance for your specific requirements, there are various actions you can undertake.

El Ali suggests evaluating your healthcare requirements, including factors like the frequency of doctor appointments, medications, and any particular medical conditions that you or your family members may have.
Assess the various healthcare options within your locality. EPOs, HMOs, and PPOs operate in distinct ways. While an HMO may offer lower costs, it also imposes more limitations on coverage. On the other hand, a PPO entails higher expenses but grants you the flexibility to seek care outside of the network. Familiarizing yourself with the characteristics and advantages/disadvantages of each plan type will enable you to discover the most suitable option for your needs.

When evaluating health insurance options, it is important to consider the differences in benefits, deductibles, copayments, out-of-pocket expenses, and premiums among various plans. It is equally crucial to thoroughly review what a plan does not cover to ensure it aligns with your specific requirements. To simplify the process of comparing plans, marketplace offerings provide a summary of benefits and coverage (SBC).
To ensure adequate network coverage, it is crucial to verify whether your preferred doctors or healthcare facilities are included in the plan you are contemplating, as advised by Agarwal. Failure to do so may result in costly out-of-network expenses or necessitate finding a new healthcare provider.

Verify the availability of prescription coverage. If you rely on prescription medications, ensure that the plan includes them and ascertain the extent of your personal expenses. It may be necessary to contact the insurance provider directly in order to obtain accurate cost information.

When searching for additional perks, consider options such as telehealth services, access to a round-the-clock nurse helpline, or potential discounts on wellness programs.
Determine if you qualify for financial aid. There is a possibility that you meet the criteria for financial assistance or premium subsidies if you decide to obtain health insurance from the Marketplace.

Engage in conversations with colleagues, friends, and relatives to gather insights on their encounters with insurance companies and policies. Request their feedback and recommendations to gain a better understanding of their experiences.