Health insurance plan covers doctor office visits

When you check into how your health insurance plan covers doctor office visits, ask about the difference in coverage between routine visits, such as checkups and wellness services, and visits for illness or injury. Some plans may pay differently, depending on the reason for the visit and whether the provider is in or out of the plan network. Plans may require copayments, set annual limits for wellness services, or require that you meet a deductible before they pay anything.

Preventive Care

Preventive care covers a wide range of services, all intended to promote and maintain health. Preventive medicine may include the following:

- Blood pressure control

- Diet and exercise counseling

- Family counseling

- Immunizations for tuberculosis and influenza

- Mammograms and Pap smears

- Regular, routine physicals

- Risk management and substance abuse counseling, including education about the dangers of tobacco, alcohol, drug use, and high-risk sexual behaviors

- Screening for cancer, tuberculosis, cholesterol, and AIDS

- Well-baby checkups

When you have no symptoms, many traditional health insurance plans pay little or nothing for preventive care. HMOs believe that detecting illness early may enhance the likelihood of appropriate and successful treatment. HMOs receive a fixed fee for covered medical expenses. They find that they save money in the long-term by paying for preventive care, which catches problems before they require expensive treatment. Covered services vary among HMOs, so as always, check the details of your plan. Most PPOs also cover preventive care.

Maternity Care

health insurance plans vary in the way they treat maternity and childbirth expenses. Some policies provide benefits for pregnancy complications but not for normal deliveries. Many policies won’t pay for certain procedures, such as elective cesarean deliveries or abortions.

In some cases, you may need to add a rider (a document that changes provisions in the original policy) to your basic health insurance policy to get coverage for prenatal care, normal delivery services, and routine, newborn nursery care (at the hospital). Such a plan may have a separate lifetime maximum amount for normal maternity services.

Maternity riders are generally very expensive, with high premiums and low caps on coverage. For example, the cost of the rider may be equivalent to 40 percent of the cap. In addition, a maternity rider may provide no benefits the first year, 50 percent of the cap during the second year, and full coverage after that.

The Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) sets the minimum number of days in the hospital after giving birth for which group health plans, insurance companies, and HMOs must provide coverage. This act applies only to those plans that already provide coverage for hospital stays related to childbirth. After a normal, vaginal delivery, most plans must generally provide coverage for at least 48 hours for both the mother and newborn child. Health coverage for a hospital stay after a cesarean delivery must generally be at least 96 hours for both the mother and newborn child. NMHPA’s requirements affect health plans beginning on or after January 1, 1998.

Infertility Treatment

Whether your health insurance plan covers infertility treatment may depend on government regulations. State regulations governing infertility treatment apply to health insurance that you buy on your own and that your employer buys. ERISA governs employers’ self-insured plans.

Government regulations

If the state you live in has an infertility insurance mandate, you are entitled to infertility coverage, especially if the mandate is a hard mandate or a mandate to provide, meaning that health insurance underwriters must provide coverage. A mandate to offer or soft mandate requires underwriters to offer coverage to employees. Employers aren’t obligated to buy the coverage.

Some health insurance plans, such as the ones that churches and school districts buy, may also be exempt from state regulation. ERISA (Employee Retirement Income Security Act) regulates employers’ self-insured plans, which are exempt from state mandates. ERISA has no provision for infertility treatment.