What Services are Covered?

Common Questions About Services Covered

This information was adapted from information provided by The Hospital Association of Pennsylvania. You can contact the Association at (570) 564-9200.

In all likelihood, the health insurance plans available to you differ in the services they cover. By reading each plan's subscriber agreement or membership handbook carefully, you'll be able to identify the plan that offers the right combination of services for your needs.

Is preventive care covered?

Preventive care is routine care. Examples of preventive care include well-baby checkups, immunization and booster shots, annual gynecological exams, physicals and mammograms. Pennsylvania law requires all individual and group health plans to pay for childhood immunizations, annual gynecologic exams and routine pap smears.

Although these services must be paid for, some traditional health plans may not pay for the office visit to receive these services. Most managed care plans pay for both the services and the office visit, but require you to pay a small co-payment.

Does the plan cover urgent care?

Urgent care is different from emergency care. Urgent care is considered care that you need when you have an illness or minor injury. Emergency care is care that you seek in a life or death situation, such as if you've been involved in a serious accident or if you think you are having a heart attack.

Most managed care plans will require that you call your insurance company before you seek urgent care. If you use the emergency room for what is considered a routine physician visit, you will be responsible for paying the bill.

In an emergency, you should go immediately to the hospital and call your insurance company later when your condition has stabilized, or have a family member call as soon as possible. Some plans require that you call your insurance company within a certain number of hours after admission to a hospital – normally 24 hours.

Does the plan cover other benefits?

Other benefits include prescription medications, vision care (eye glasses or contact lenses), dental care and hearing screening. If your plan covers these services, you probably will have to pay part of the cost of these services with a co-payment. You also may have to meet a deductible before your insurance will begin to pay for these services. If your health plan does not cover these benefits, you may be able to buy separate benefit plans for these additional services. Check your plan contracts to see it there are limitations on the amount of each of these serves the plans will pay for.

Does the service area meet your needs?

Traditional insurance plans generally pay for care no matter where you receive it. However, participating networks do influence service reimbursement amounts. Managed care plans generally operate in a given coverage area. The coverage area will be described in the plan's subscriber agreement. Typically, you must seek care from participating providers in that coverage area. If you are out of town and become ill or injured, managed care plans prefer, if possible, that you return home and see your primary care physician. If you are away and have an emergency, you should seek care immediately and call your insurance company as soon as possible. Managed care plans are required to pay for emergency care you receive out of the coverage area.

Does the plan cover pre-existing conditions?

Some health insurance plans will not pay for services you receive to treat an illness or injury you had before your contract begins. Others will cover pre-existing conditions, such as diabetes, cancer and heart problems, only after a certain time has gone by. This will change when all healthcare reform elements have been instituted.

Other Common Questions:

  • How much will it cost?
  • What physicians are available to you?