Standard major medical insurance is built around medically necessary care. Everything else is either excluded, covered only in limited circumstances, or requires a separate policy. Use this reference to know what to expect before you schedule — not after you get the bill.
| Service | Covered? | Exception / workaround |
|---|---|---|
| Routine dental (cleanings, fillings, crowns) | No | Add standalone dental plan; pediatric dental required for under-19 on marketplace |
| Routine vision (eye exams, glasses, contacts) | No | Standalone vision plan (~$15/mo); medical eye conditions ARE covered under health plan |
| Cosmetic surgery | No | If medically necessary (e.g., reconstruction after mastectomy, breathing obstruction), may be covered with prior auth |
| Hearing aids | No | Some Medicare Advantage and employer plans add this; standalone hearing aid coverage available |
| Long-term / custodial care (nursing home, assisted living) | No | Medicaid covers LTC for those who qualify; separate long-term care insurance for everyone else |
| Infertility treatment (IVF, IUI) | Varies | ~20 states mandate some fertility coverage; marketplace plans frequently exclude it |
| Acupuncture, naturopathy, massage therapy | No | Limited acupuncture added to some plans post-2020; most alternative care remains excluded |
| Weight loss drugs (GLP-1s like Ozempic, Wegovy) | Varies | Coverage expanded significantly 2024–2026 but still inconsistent; check your plan’s formulary |
| Experimental treatments / unapproved drugs | No | Routine care costs for approved clinical trials (cancer, life-threatening conditions) must be covered |
| Out-of-network care (HMO/EPO plans) | No | Emergency care always covered; request a network gap exception if no in-network specialist available |
What Standard Health Insurance Does Not Cover
Standard major medical insurance is built around medically necessary care, but there are many services that most plans — including ACA marketplace plans — either exclude entirely or cover only in limited ways. Understanding these exclusions before you need care helps you avoid unexpected bills and plan for additional coverage where necessary.
Cosmetic and Elective Procedures
Cosmetic surgery and elective procedures performed for aesthetic reasons rather than medical necessity are typically excluded. Examples: rhinoplasty (nose reshaping), facelifts, liposuction, breast augmentation (when not medically required), eyelid surgery for cosmetic purposes, Botox for wrinkles, and LASIK eye surgery. If a procedure is medically necessary — for example, rhinoplasty to correct a breathing obstruction, or breast reconstruction after mastectomy — it may be covered. The distinction between cosmetic and medically necessary often requires prior authorization and documentation from your physician.
Dental Care
Routine dental care — cleanings, fillings, crowns, root canals, extractions, orthodontics — is not covered under standard health insurance plans. The ACA does not require adult dental coverage as an essential health benefit, though it does require pediatric dental coverage for children under 19. Adults needing dental coverage should purchase a standalone dental plan or enroll in a dental plan alongside their health plan. Some health plans cover emergency dental treatment for injuries (like a knocked-out tooth) but not routine care.
Vision Care
Routine vision care — eye exams for glasses or contacts, prescription eyeglasses, and contact lenses — is generally not covered under health insurance. Like dental, pediatric vision is an ACA essential health benefit for children, but adults typically need a separate vision plan. Note: health insurance does cover medical eye conditions (glaucoma, cataracts, diabetic retinopathy, eye injuries) as they are medical diagnoses, not routine vision care.
Long-Term Care and Custodial Care
Long-term care — assistance with daily living activities (bathing, dressing, eating) in a nursing home, assisted living facility, or at home — is not covered by standard health insurance. Medicare covers limited skilled nursing facility care after a hospitalization, but does not cover indefinite custodial care. Medicaid covers long-term care for those who meet income and asset requirements. For everyone else, long-term care insurance is a separate product.
Hearing Aids
Most health insurance plans do not cover hearing aids or routine hearing aid fittings, despite hearing loss being extremely common. ACA plans do not list hearing aids as an essential health benefit. Some employer plans, Medicare Advantage plans, and some state Medicaid programs have added hearing aid benefits in recent years, so check your specific plan.
Infertility Treatment (Varies by State and Plan)
Coverage for infertility treatment — IVF, IUI, fertility medications — varies significantly by state law and plan design. Some states mandate fertility coverage; many do not. Individual marketplace plans frequently exclude or limit fertility treatment. Check your plan's Summary of Benefits and Coverage carefully if this is a consideration.
Alternative Medicine (Largely Excluded)
Acupuncture, naturopathy, homeopathy, massage therapy, and most alternative or complementary medicine is not covered by standard health plans. Some plans have added limited acupuncture coverage, and some employer plans include wellness benefits. Chiropractic care coverage also varies widely by plan.
Weight Loss Programs and Bariatric Surgery
Commercial weight loss programs (Weight Watchers, Noom, meal plans) are not covered. Bariatric surgery (gastric bypass, gastric sleeve) is covered by some plans when medical necessity criteria are met, but excluded on others. Coverage for FDA-approved weight loss medications has expanded significantly in 2024–2026 but still varies by plan.
Experimental Treatments and Clinical Trials
Treatments that are not FDA-approved or are classified as experimental are generally excluded. Routine care costs associated with participating in a clinical trial may be covered, but the experimental drug or device itself is not. The ACA requires plans to cover routine costs for patients in approved clinical trials for cancer and life-threatening diseases.
Non-Emergency Out-of-Network Care (for HMO/EPO Plans)
HMO and EPO plans do not cover non-emergency care received outside the plan's network. If you see an out-of-network provider, you pay the full cost (the plan pays nothing). This is a significant gap if you travel frequently, have established care with a provider who is not in-network, or need a specialist unavailable in-network.
When These Gaps Matter Most
For dental, vision, and hearing needs, standalone supplemental plans are available and often affordable. For long-term care, a separate long-term care insurance policy is the primary solution. A licensed broker can help you identify which gaps matter most for your situation and what supplemental products are available. Call (713) 575-9904 for a free review.