Health Care Benefits

Use this worksheet:
Ask About Benefits

When you join a health plan, you want to know that you will get the health care services you need. HMOs must cover the basic benefits listed below. If you join a PPO, ask for information on the benefits that are covered.

Topics on this page

• Basic benefits
• Optional benefits
• Other services

Basic benefits that health plans usually cover

• Doctor services
• Hospital services, including inpatient services—when you have to stay overnight in the hospital—and outpatient services, such as minor surgery in a surgery center
• Many laboratory tests
• Diagnostic services, like X-rays and mammograms
• Preventive and routine care, like vaccinations and regular checkups
• Mental health care for some serious problems
• Emergency and urgent care—even if you are outside your health plan's service area
• Rehabilitation therapy, such as physical, occupational and speech therapy
• Some home health or nursing home care after a hospital stay
• More information about benefits  

These services may not be covered at all, or only partly covered

• Prescription drugs—many plans do cover prescription drugs, but costs vary a great deal.
• Durable medical equipment, such as wheelchairs and oxygen—what is covered varies a lot and there may be a limit on what the plan will pay in a year.
• Dental care
• Eyeglasses
• Hearing aids

Other services that HMOs usually offer

• Health education programs, such as classes and support groups to help you stop smoking, prepare for childbirth, learn to control diabetes, and more. You can compare how plans help smokers quit.
• A customer/member service helpline that you can call for help or information or if you have a problem. You can compare how members rate their plans on customer service.
• 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. You can compare how plans rate on language assistance services.

Back to the Top