Our agents hear it all the time, “is it covered?” You’ve probably asked this question before when buying health insurance, be it out loud or just in your head. Before every doctor visit or procedure, I ask it myself, too… However, I’ve only recently realized that what I’m asking is not what I really mean…

Say What You Mean and Mean What You Say

For me personally, when I ask if something is covered, what I really want to know is if a certain service is free. If that’s what we really mean, why don’t we drop the ambiguous language and just ask? Doing so could clear up a lot of confusion, because asking if something is covered does not necessarily mean free in the world of health insurance.

A health insurance agent has a different definition of the word covered than you likely do. To them, when a service is covered, your insurance company pays for all or some of it- be that through a copayment, deductible, coinsurance, or other stipulations written into your policy. To an agent, “covered” means that your plan will at least help pay for a service.

Covered Does Not Mean Free

When I first learned about the Affordable Care Act/Obamacare, I read that a list of essential health benefits were required to be covered by Marketplace plans. At the time, I had a Marketplace plan and needed to have an antibiotic prescription filled. An essential benefit that was required to be covered is prescription medications. When I had to pay a whopping $10 for my antibiotic, I was wildly confused. I thought my prescriptions were “covered”… Now I realize that they were covered, they were just subject to my copayment. My insurance company helped pay for my prescription, they just didn’t pay for all of it.

I’ve also had various tests completed by my doctor when enrolled in a Marketplace plan, again thinking they were covered (per my definition- i.e. free…), and then being outraged when I still received a bill in the mail. After further investigation of my plan and its summary of benefits, I again had the realization that covered did not mean free and that many of the tests I had done were subject to my coinsurance and deductible. This meant that my 20% coinsurance (I pay 20%, my insurance provider pays 80%) didn’t even kick in until after I met my $1000 deductible. I hadn’t met my deductible, so I paid for the tests. Again, these services were technically covered, just subject to my coinsurance and deductible.

When in Doubt, Ask

When you speak with an agent to enroll in a health plan, be specific with the questions you ask. If you want to know if something is free, simply ask that question. If you still want to ask if a certain service is covered, ask how much is covered and how much you’re responsible for paying. Doing this is one of the most effective ways to ensure that you know what coverage you are getting, and also the most effective way to make sure you and your agent are on the same page. This way, you can avoid the confusion of a surprise medical bill- because you’ll already know what’s “covered.” 🙂