Health Plan Benefits
When you join a health plan, you want to know that you will get the health care services you need. Always ask for information on the benefits that are covered. Remember, some services are usually not covered. For example, many health plans do not cover hearing aids.
Most new health plans must offer a complete set of essential benefits. Read more below.
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If you aren't sure what services your health plan covers, you can:
- Ask your employer (if you get your health plan through your job).
- Look at your plan’s website.
- Call your plan's member/customer services number.
- Talk to your doctor.
- Read your plan's policy or Evidence of Coverage, or the shorter Summary of Benefits. Ask your plan or employer for a copy.
Most new health plans must offer the essential health benefits listed below.
- Children's services, including dental and vision care
- Chronic disease management
- Doctor and specialist care
- Emergency services, even if you are outside your health plan's service area
- Hospital services, including inpatient care with an overnight stay and outpatient care when you do not stay overnight
- Lab services
- Maternity and newborn care
- Mental health and substance abuse services
- Prescription drugs
- Rehabilitation services and equipment
- Preventive and wellness services
There are some basic benefits that HMOs and some PPOs have to cover. They are similar in many ways to the essential benefits listed above. However, these are some important differences:
- Individual plans might not cover prenatal and newborn care.
- Mental health care may be limited to certain serious problems.
- Many plans do not cover prescription drugs.
Most HMOs and many PPOs offer these services:
- Health education programs, such as classes and support groups to help you stop smoking, prepare for childbirth, learn to control diabetes, and more.
- A customer/member service helpline that you can call for help or information or if you have a problem.
- A 24-hour advice nurse helpline that you can call if you need advice on a health problem, such as a sick child or a sprained ankle.
- Language assistance if you need an interpreter or a doctor who speaks your language. Learn more about language assistance.
OPA worksheet: Ask About Benefits
Compare benefits and providers
Using plan services