What a Fee-for-Service Health Insurance Plan Will Normally Cover

Fee-for-service health insurance (often called FFS, indemnity, or traditional health insurance) works differently from HMOs and PPOs. Instead of being limited to a network of providers, you can usually see any doctor or hospital you choose, and the plan reimburses a portion of the bill.

Understanding what a fee-for-service health insurance plan will normally cover can help you avoid surprises, plan for out-of-pocket costs, and decide whether this type of coverage fits your needs.

How Fee‑for‑Service Health Insurance Works

With a fee-for-service plan, the insurance company pays for covered services after you receive care. You or your provider submit a claim, and the insurer reimburses a percentage of the “reasonable and customary” charge, after your deductible and coinsurance.

Key features:

• Freedom to choose providers (usually no network requirement)
• You pay first, then get reimbursed (or the provider bills the insurer directly)
• Coverage is split between what the plan pays and what you pay out of pocket

From there, what’s covered looks similar to many other major medical plans—but the details matter.

Core Medical Services a Fee‑for‑Service Plan Will Normally Cover

Most standard fee-for-service health insurance plans focus on medically necessary care. Here are the categories typically included.

1. Hospital Care (Inpatient Services)

Fee-for-service plans usually cover a wide range of hospital services, such as:

• Room and board (semi-private room is common)
• Surgery and procedures performed in the hospital
• Diagnostic tests (like X-rays, CT scans, MRIs)
• Nursing care while you’re admitted
• Medication given during your hospital stay

You can expect:

• A deductible (for example, a set amount per benefit period)
• Coinsurance (you may pay a percentage of the bill, such as 20%)
• Possible limits on the number of days covered for certain services

2. Outpatient and Physician Services

Most fee-for-service health insurance plans cover doctor visits and outpatient care, including:

• Primary care visits
• Specialist visits (cardiologist, dermatologist, etc.)
• Outpatient surgery or procedures
• Clinic and urgent care visits

How payment usually works:

• You see any licensed provider you choose.
• The provider bills you or your insurance.
• The plan pays a portion of the bill based on its approved amount.
• You are typically responsible for coinsurance and any amount over the approved charge.

3. Emergency Services

Fee-for-service plans generally cover emergency room (ER) care and emergency medical treatment, including:

• Ambulance transport (ground, sometimes air, depending on the policy)
• Emergency room evaluation and treatment
• Stabilization and immediate care after serious injury or sudden illness

You may face:

• A separate ER copayment or higher coinsurance
• Additional charges if the plan’s “reasonable and customary” allowance is lower than the hospital bill

Even with fee-for-service flexibility, it’s helpful to check in advance how your plan defines an “emergency” and what’s covered.

4. Preventive and Routine Care

Modern fee-for-service health insurance plans often include preventive care, though specifics vary. Commonly covered preventive services can include:

• Annual physical exams
• Routine screenings (blood pressure, cholesterol, some cancer screenings)
• Vaccines and immunizations
• Well-child visits and routine pediatric care

Some plans cover these at no cost to you if certain conditions are met (for example, using particular providers or following recommended schedules). Others apply the deductible and coinsurance.

Always verify:

• Whether preventive services are covered before the deductible
• Which tests and vaccines are considered “preventive” under your policy

5. Diagnostic Tests and Imaging

Most fee-for-service plans cover diagnostic testing, such as:

• Lab tests (blood work, urine tests, biopsies)
• Imaging (X-rays, ultrasounds, CT scans, MRIs)
• Cardiac tests (EKGs, stress tests)

Coverage typically includes:

• Payment of a set percentage of approved charges
• Possible rules about prior authorization for high-cost tests

6. Surgery and Anesthesia

Whether performed inpatient or outpatient, fee-for-service plans usually cover:

• Surgeon fees
• Anesthesiologist fees
• Operating room facilities and equipment
• Post-surgical hospital care

Your share depends on:

• Whether you met the deductible
• Your plan’s coinsurance rate
• How the plan defines reasonable and customary costs in your area

7. Maternity and Newborn Care

Many comprehensive fee-for-service health plans cover maternity services, including:

• Prenatal visits
• Labor and delivery (hospital or birthing center, depending on the plan)
• Newborn exam and initial hospital care

Important to check in your policy:

• Is maternity covered at all?
• Are there waiting periods or pre-enrollment requirements?
• What’s the coverage for complications of pregnancy?

8. Mental Health and Substance Use Services

In many modern plans, mental health and substance use disorder services receive coverage similar to physical health services. Under many configurations of fee-for-service:

• Outpatient therapy or counseling visits may be covered
• Psychiatric evaluations and medication management may be included
• Inpatient mental health treatment or rehab may be covered with limits

However, older or less comprehensive fee-for-service plans may have:

• Visit limits per year
• Higher copayments or coinsurance
• Different deductibles for mental health services

Review your mental health benefits section carefully if this coverage is important to you.

Additional Services That May or May Not Be Covered

Some services fall into a “maybe” category—often covered by some fee-for-service health insurance policies but limited or excluded by others.

1. Prescription Drugs

Prescription coverage under fee-for-service can vary widely:

• Some plans include a built-in prescription drug benefit.
• Others require a separate prescription plan.
• A few may offer only limited or no prescription coverage.

Common features when drugs are covered:

• A formulary (list of covered medications)
• Tiers (generic, preferred brand, non-preferred brand, specialty) with different costs
• Quantity limits or prior authorization for certain medications

2. Rehabilitation and Therapy Services

Coverage may include:

• Physical therapy
• Occupational therapy
• Speech therapy
• Cardiac or pulmonary rehab

But often with:

• Limits on number of visits per condition or per year
• Different cost sharing compared with regular doctor visits

3. Home Health Care and Skilled Nursing

Some fee-for-service plans cover home health services and skilled nursing facility care when medically necessary, such as:

• Skilled nursing visits
• Rehabilitation services at home
• Short-term stays in a skilled nursing facility after hospitalization

Restrictions may include:

• Maximum days covered per benefit period
• Requirements that care be intermittent, short-term, or tied to a recent hospital stay

4. Durable Medical Equipment (DME)

Plans may cover durable medical equipment, such as:

• Wheelchairs and walkers
• Home oxygen equipment
• Certain braces or support devices

Coverage often includes:

• Prior authorization requirements
• Separate coinsurance percentage
• Rules on renting vs. buying equipment

5. Telehealth and Virtual Care

Some fee-for-service policies now cover:

• Telehealth visits with doctors or therapists
• Online urgent care consultations

Others may not, or they may only cover telehealth during specific circumstances. This is a good item to confirm directly.

Common Exclusions in Fee‑for‑Service Plans

Just because fee-for-service plans are flexible about which providers you see doesn’t mean they cover every type of care.

Many plans exclude or limit:

• Cosmetic procedures (for appearance only, not medically necessary)
• Experimental or investigational treatments
• Long-term custodial care (help with daily activities in nursing homes or at home)
• Routine vision and dental care for adults
• Hearing aids and routine hearing exams
• Over-the-counter drugs and supplies
• Alternative or complementary therapies (such as acupuncture, chiropractic beyond limits, or naturopathic care, depending on the policy)

Each plan defines these categories differently, so it’s important to read your exclusions and limitations section carefully.

How Cost Sharing Works in Fee‑for‑Service Health Insurance

Understanding what’s covered also means understanding how much is covered and what you’ll pay yourself.

Key Terms to Know

• Premium: What you pay each month to keep the coverage active.
• Deductible: What you must pay out of pocket each year before the plan starts paying for covered services (except certain preventive care, in some plans).
• Coinsurance: The percentage of costs you pay after meeting the deductible (for example, 20%).
• Copayment (copay): A fixed amount you pay for specific services (for example, $30 per office visit), if your plan uses copays.
• Reasonable and customary charge: The amount your insurer decides is appropriate for a particular service in your area. If your doctor charges more, you might pay the difference.

Example: How a Covered Service Might Be Paid

Imagine:

• Your deductible is $1,000 per year.
• Your coinsurance is 20% after the deductible.
• The insurer’s reasonable and customary amount for a procedure is $2,000.
• You haven’t yet met your deductible this year.

How it might work:

1. You receive the service.
2. You pay the first $1,000 (your deductible).
3. On the remaining $1,000, the plan pays 80% ($800), and you pay 20% ($200).
4. Your total out-of-pocket cost is $1,200.

If the provider billed $2,300 and your plan only considers $2,000 reasonable, you may also owe the additional $300, depending on your policy.

Quick Coverage Snapshot

Use this as a general guide, keeping in mind that your specific plan may differ.

How to Find Out Exactly What Your Plan Covers

Because fee-for-service health insurance can vary so much, it’s essential to confirm details for your own policy.

Here’s a practical checklist:

1. Get your Summary of Benefits and Coverage (SBC).

   • Look for sections on hospital, physician, emergency, prescription, and mental health services.

2. Check the exclusions and limitations section.

   • Flag items like cosmetic, fertility treatments, and alternative therapies if those matter to you.

3. Review any separate prescription drug or mental health riders.

   • Some benefits are carved out into separate coverage documents.

4. Look for prior authorization requirements.

   • These can affect coverage for high-cost tests, equipment, or treatments.

5. Call customer service if anything is unclear.

   • Ask how a specific service (for example, physical therapy, a certain medication, or a planned surgery) is handled.

When a Fee‑for‑Service Plan May Be a Good Fit

Consumers often consider fee-for-service plans when they:

• Want maximum choice of doctors and hospitals
• Already see providers who do not participate in managed care networks
• Prefer the ability to seek care from specialists directly, without referrals

In exchange, these plans may come with:

• Higher premiums compared with many managed care options
• More paperwork (claims, reimbursement forms) in some cases
• Greater variation in out-of-pocket costs if provider charges exceed the plan’s allowed amounts

Understanding what the plan normally covers—and how costs are shared—can help you decide if the tradeoffs align with your priorities.

Key Takeaways

• A fee-for-service health insurance plan will normally cover:

  • Inpatient hospital care
  • Outpatient and physician services
  • Emergency care
  • Many forms of diagnostic testing, surgery, and maternity services
  • Often preventive care, mental health services, and sometimes prescription drugs

• Coverage focuses on medically necessary services, with significant variation among plans in areas like prescription drugs, rehab, home health, and mental health.

• You gain more freedom of provider choice but often take on more cost responsibility and the need to understand deductibles, coinsurance, and reasonable and customary charges.

If you have a specific fee-for-service policy in mind, the most reliable way to know what it will cover is to read your plan documents closely and confirm details with the insurer before receiving non-emergency care.