General Health Insurance Benefit Information

Health Insurance Coverage Can be Confusing
Trying to understand your insurance coverage is often confusing, especially regarding what it covers or does not cover. We provide some basic information for your review. However, we recommend you check with your insurance carrier prior to seeking treatment for your specific benefits.
Illustration of doctor and patient at table reviewing a health checkup

Health Insurance usually covers the following:

Pays for part of your medical bills if your medical care that does not require prior authorization.

Provides coverage preventive care services, like cancer screenings or annual check-ups.

Depending on your insurance coverage you may have coverage for the following:

More specific benefit information is listed in the taps below.

Along with confusing health benefits is the coverage terms you need to know:

Premium: This is the monthly payment you make to have insurance. Think of it like a gym membership or car payment. You still must pay the same amount each month even if you do not use the coverage that month.

Deductible: Some insurances charge a deductible, which restarts every year. It is the predetermined amount that you must pay for health care services before your health coverage is available. Deductibles are most common with HMO coverages.

Copayment (also known as a copay): To keep the insurance carriers’ costs down, some insurance plans have copays. These are usually fixed amounts you pay each time you see a medical provider.

Coinsurance: Not the same as a copay, coinsurance is a percentage of your bill that you pay after you have paid your yearly deductible. For example, if you have a 20% coinsurance, you pay 20% of the bill and your insurance pays the remaining 80%, once you have met your deductible.

Out-of-Pocket Maximum: This is the maximum you will have to pay out of your own pocket for covered health expenses. Once you hit the maximum, your insurance will pay 100% of your health care costs for covered services for the remainder of the year.

HMOs is a Health Maintenance Organization. An HMO is a network of doctors, hospitals and other healthcare providers who agree to provide care at a lower fee.  HMOs often require you to select a primary care physician (PCP), and all specialist services must be approved by the PCP when needed. HMO plans are generally less expensive than PPO plans, with lower monthly premiums, making them cost effect if your doctors are already in the network.

PPOs is a Preferred Provider Organization. Like an HMO, a Preferred Provider Organization is a network of doctors, hospitals and healthcare providers who agree to provide care at a certain rate. Unlike an HMO, you are not limited to providers who are in that network. PPO plans generally require higher monthly premiums than HMOs. With a PPO, you do not need to designate a primary care physician and usually can see the provider of your choice at any time, including specialists.

Based on Insurance tips for your dermatology visit hosted by Pacific Dermatology Specialist:

Before your first dermatology appointment, you’ll want to call the office and ask if they take your insurance. Most offices accept a wide range of plans. If they don’t accept your insurance plan, ask about payment plans to help you cover your visit. Keep in mind that you might have a co-pay at the visit, so be sure to be prepared for that cost.

Remember that if your primary care physician is providing a referral for a dermatologist, they’ll likely recommend an office in-network. However, you’ll need to do this research yourself if you’re making a dermatology appointment on your own.

Know What Services Your Insurance Company Covers

Once you confirm that the dermatology provider accepts your insurance plan, you’ll want to find out which services are covered by your insurance company. As a rule, most insurance companies will cover services that they deem medically necessary. While many cosmetic dermatology treatments are excluded, most medical and surgical services are covered. This may include:

  • Skin Cancer Services: Insurance companies generally cover skin cancer dermatology services, since these are either medically necessary or pertain to preventative health care. These services may include skin cancer screenings, mole removal, procedures like Mohs surgery, and other skin cancer treatments.
  • Acne Treatment: Dermatology treatments for acne are often covered by insurance. These might include laser or light therapy, topical medications, dermatologist chemical peels, and clinical facials.
  • Skin Condition Treatment: If you have a skin condition like psoriasis, eczema, fungal infections, hives, and warts, insurance will likely cover treatment. This is because treatment of these infections is generally necessary for your health.
  • Medications: Insurance often covers prescriptions for dermatology treatments. This is true for topical and oral medications, but you’ll want to check your insurance plan to be sure.

Keep in mind that each insurance plan is different, so the above conditions may not fall under your coverage. You can avoid any surprises by contacting your insurance company and confirming their scope of coverage.

Will Medicare Help Pay for Melanoma Screenings by a Dermatologist?

Medicare may cover a dermatologist visit for further assessment, if your doctor refers you. Medicare will pay for a dermatology visit if it is medically necessary, such as to check or further assess a skin spot or mole. But a preventive melanoma screening or skin check by a dermatologist is generally not covered. If you have a Medicare Advantage plan, call your plan to learn about specific coverage details.

Colorectal Cancer

If you are age 50 to 75, get tested regularly for colorectal cancer. A special test (called a screening test) can help prevent colorectal cancer or find it early, when it may be easier to treat.

You may need to get tested before age 50 if colorectal cancer runs in your family. Talk with your doctor and ask about your risk for colorectal cancer.

Know What Services Your Insurance Company Covers

Under the Affordable Care Act, the health care reform law passed in 2010, most health insurance plans must cover screening for colorectal cancer. Depending on your plan, you may be able to get screened at no cost to you.

For Medicare patients

Medicare Part B covers different colorectal cancer screenings, each with separate eligibility requirements:

  • Fecal occult blood test – once a year (every 12 months) if you are age 50+
  • Flexible sigmoidoscopy – once every four years (48 months) if you are age 50+ and at high risk, or once every 10 years after a colonoscopy if you are age 50+ and not at high risk
  • Colonoscopy – once every two years (24 months) if you are at high risk, or once every 10 years if you are not at high risk (but not within 48 months of a flexible sigmoidoscopy)
  • Barium enema – once every two years (24 months) if you are age 50+ and at high risk, or once every four years (48 months) if you are age 50+ and not at high risk (but not within 48 months of a flexible sigmoidoscopy)


  • If you qualify, Original Medicare covers fecal occult blood tests, flexible sigmoidoscopies, and colonoscopies at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Plans are required to cover these tests without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.

Barium enemas are covered at 80% of the Medicare-approved amount. When you receive the service from a participating provider, you pay a 20% coinsurance after you meet your Part B deductible. If you are enrolled in a Medicare Advantage Plan, contact your plan for cost and coverage information for barium enemas. Your plan’s cost-sharing may apply when seeing in-network providers.

What about cost?

Under the Affordable Care Act, insurance plans must cover:

  • Diabetes screening for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease

Depending on your insurance plan, you may be able to get these services at no cost to you. Check with your insurance provider to find out what’s included in your plan.

For Medicare

Medicare Part B (Medical Insurance) covers glucose laboratory test screenings (with or without a carbohydrate challenge) if your doctor determines you’re at risk for developing diabetes. You may be eligible for up to 2 screenings each year. Part B covers these lab tests if you have any of these risk factors:

  • High blood pressure (hypertension)
  • History of abnormal cholesterol and triglyceride levels (dyslipidemia)
  • Obesity
  • A history of high blood sugar (glucose)

Medicare also covers these screenings if 2 or more of these apply to you:

  • You’re age 65 or older.
  • You’re overweight.
  • You have a family history of diabetes (parents or siblings).
  • You have a history of gestational diabetes (diabetes during pregnancy) or delivery of a baby weighing more than 9 pounds.

Your costs in Original Medicare

You pay nothing for these tests if your doctor or other qualified health care provider accepts Assignment.

Things to know

Starting January 1, 2021, you may be able to get Medicare drug coverage that offers broad access to many types of insulin for no more than $35 for a 30-day supply. You can get this savings on insulin if you join a Medicare drug plan or Medicare Advantage Plan with drug coverage that participates in the insulin savings model. This model lets you choose among drug plans that offer insulin at a predictable and affordable cost.

Find a plan that offers this savings on insulin in your state. You can also filter and compare participating plans to help you find the plan that’s right for you. You can join during yearly Open Enrollment (October 15 – December 7).

What about the cost of testing?

Under the Affordable Care Act, the health care reform law passed in 2010, insurance plans must cover blood pressure testing. Depending on your insurance, you may be able to get your blood pressure checked by a doctor or nurse at no cost to you.

Check with your insurance company to find out what’s included in your plan.