Health Insurance: What's Covered and How It Works

The deductible is what you pay for covered care before the plan starts sharing costs; after that you usually pay coinsurance or copays. The out-of-pocket maximum is the most you'll pay in a year for in-network covered care — once you hit it, the plan pays 100% of covered services for the rest of the year. Premiums don't count toward either, and out-of-network care may not count toward the in-network max.

In-network preventive services required by the ACA — annual wellness visits, many screenings, immunizations, and contraception — are covered with no cost-sharing on non-grandfathered plans, even before you meet your deductible. The catch is coding: if a preventive visit turns into treatment of a problem, that portion can be billed as a regular (cost-shared) service. Confirm the visit is coded as preventive.

Prior authorization means the plan must approve certain services, drugs, or procedures before it will cover them. Your provider submits the request; the plan can approve, deny, or ask for more information. A denial can be appealed — first internally with the insurer, then through an external review — and plans must tell you why and how to appeal. Emergency care doesn't require prior authorization.

Yes for the emergency itself. Federal law requires plans to cover emergency care without prior authorization and at in-network cost-sharing even at an out-of-network ER, and the No Surprises Act protects you from most surprise balance bills for emergency services and many out-of-network providers at in-network facilities. Follow-up and non-emergency care may still be subject to out-of-network rules.

No, not on ACA-compliant plans. Marketplace and most employer plans can't deny you, charge you more, or exclude coverage because of a pre-existing condition, and there's no waiting period for it. The exception is non-ACA products like short-term health plans, which can screen for and exclude pre-existing conditions — a key reason to read what you're buying.

Generally yes. ACA plans must cover mental health and substance-use services as an essential health benefit, and federal parity law requires that coverage to be no more restrictive than for medical care. Coverage details — networks, prior authorization, and visit limits — still vary by plan, so check your plan's behavioral-health network and rules.

On an HMO or EPO, non-emergency out-of-network care is generally not covered, so you could pay the full bill. On a PPO, it's covered at a higher cost share, and the provider may balance-bill you for the difference between their charge and what the plan allows. Always verify a provider is in-network before a planned visit — 'accepts my insurance' isn't the same as 'in-network.'