What Does Private Health Insurance Cover?

If you have health insurance in the United States, you are covered under a public or private plan. Public health insurance plans are government-funded at the federal, state, or local level. They’re highly regulated and must comply with ACA standards. On the other hand, private health insurance plans are provided by private organizations that aren’t affiliated with the government. While some follow similar regulations to remain ACA-compliant, others are not regulated and offer low coverage services. 

According to the U.S. Census, an estimated 66.5% of Americans are enrolled in private health plans, as opposed to 34.8% enrolled in public plans. If you’re one of the majority or are considering enrolling in a private health insurance policy, read on to learn more about what it is and what it covers. 

Types of Private Health Insurance

While a governing body does not oversee private health insurance policies, most are highly regulated at the federal and state levels. Laws and regulations often determine which services are to be covered by individual and group plans, ensuring that the individuals covered by these insurance types receive full coverage for the following ten essential health benefits:

  1. Outpatient/ambulatory patient services
  2. Emergency services
  3. Pediatric services (including vision and oral care)
  4. Preventive/wellness services, chronic disease management
  5. Maternity and newborn care
  6. Hospitalization
  7. Habilitative and rehabilitative services
  8. Laboratory services
  9. Mental health/substance use disorder services
  10. Prescription medication

Many private individual and family plans and employer-sponsored plans meet the minimum essential coverage requirements of the Affordable Care Act (ACA). This includes grandmothered and grandfathered plans.

Low-Cost, Low Coverage

While many types of private health insurance are regulated to ensure policyholders receive the same ten essential benefits as those covered by ACA-compliant plans, several types are much less regulated and are meant to serve as temporary or supplemental coverage. These include the following:

  • Fixed indemnity plans
  • Short-term health insurance plans
  • Dental/vision plans
  • Critical illness plans
  • Accident supplements

These policies offer low-cost benefits but are less comprehensive than the plans mentioned above. Many also have cost caps, leaving you responsible for any amount that exceeds the set cap for your policy. 

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