What Are the Major Provisions of a Health Insurance Policy?

Health insurance is changing and provisions may soon be more transparent. Health insurers will provide a summary of coverage with a breakdown of the major provisions, according to the American Medical Association website. A health insurance policy is a contract, and you can get the coverage you need by reviewing the provisions.

Coverage

• Determine the coverage area for the insurance, the physicians and hospitals you can use, and what happens if you are outside the coverage area. Look for preventive care that has no deductible and no co-pay. Americans use preventive services at only about half the rate recommended, reports the U.S. Department of Health and Human Services. Preventive care should include mammograms and colonoscopies, HealthCare.gov reports.

Deductible

• Check the annual deductible, the family deductible and the annual out-of-pocket maximum you can owe. Check the provisions for emergency room care, testing, x-rays and physician's visits to determine the amount you will owe for each of these.

Co-Payment

• Look at co-payment provisions and see how much you are required to share in payment for coverage as an in-patient and as an out-patient. Twenty percent is common for health policies. Check the policy to determine the in-patient co-payment after the deductible. You may pay $500 deductible and as much as 50 percent co-pay for in-hospital care. This is large, so be sure there is a limit or total you may be required to pay annually.

Major Medical

• Once you pay a designated amount for medical bills, your policy should go into major medical coverage at 100-percent payment by the insurer. This often occurs at $3,000 or $5,000 out-of-pocket total paid by you. Be certain the policy provides major medical coverage for you and your family at 100 percent. Million-dollar coverage will be of no benefit if it only pays 80 percent, since you would still be required to pay $200,000.

Exclusions

• Items not covered in your health insurance policy are exclusions. This may include cosmetic surgery, dental care and genetic testing. Read the exclusions carefully and understand coverage you will not have.

  Use the HealthCare.gov website to compare policy provisions and get the health insurance that is best for you.