What Does a Catastrophic Plan Not Cover?

Catastrophic health plans serve as a financial safeguard against significant, unforeseen medical events. These plans are characterized by low monthly premiums coupled with very high deductibles, making them a cost-effective option for individuals who anticipate minimal healthcare needs. They are designed to protect policyholders from the financial burden of serious illnesses or injuries, rather than covering routine medical expenses. Typically, these plans are available to individuals under 30 years old, or to those of any age who qualify for a hardship or affordability exemption.

Understanding Your Financial Responsibility

Catastrophic health plans have a high deductible, which shapes a policyholder’s financial responsibility. A deductible represents the amount of money you must pay for covered healthcare services before your insurance plan begins to contribute. For these plans, the deductible is substantial, often aligning with the annual out-of-pocket maximum limit set by the Affordable Care Act (ACA). This means that for most services, you are responsible for 100% of the cost until this high deductible is fully met.

While catastrophic plans are required to cover Essential Health Benefits (EHBs) as defined by the ACA, the high deductible means the policyholder initially bears the full cost of these services. Once the deductible is satisfied, the plan pays 100% for all covered essential health benefits for the remainder of the year. For 2025, the maximum annual out-of-pocket limit, which catastrophic plan deductibles typically match, is $9,200 for self-only coverage and $18,400 for family coverage. This out-of-pocket maximum includes deductibles, copayments, and coinsurance for in-network covered services, ensuring there is a cap on how much an individual will pay in a given year.

Common Services Not Covered Before Deductible

Many common medical services, although considered Essential Health Benefits, will typically require the policyholder to pay the full cost until the high deductible of a catastrophic plan is met. Routine doctor visits for non-preventive issues, such as a general check-up not classified as preventive or an appointment for a minor illness like a common cold, fall under this category. The cost for these consultations will be entirely your responsibility until your deductible is satisfied.

Similarly, most prescription drug costs are applied towards the deductible. This means that you will likely pay the full negotiated price for medications, with the exception of certain preventive drugs, until your annual deductible has been reached. Visits to specialists, such as dermatologists, orthopedists, or allergists, for non-emergency conditions also typically require out-of-pocket payment before the plan’s benefits activate. These costs contribute to meeting your deductible.

Any non-emergency hospital admissions or planned medical procedures, regardless of their medical necessity, will generally require the policyholder to cover the costs up to the deductible amount before insurance coverage begins. This includes scheduled surgeries or diagnostic tests. Mental health and substance use disorder services, while mandated as Essential Health Benefits, are also subject to the high deductible, meaning initial expenses for therapy sessions or treatment programs will be paid by the policyholder.

Explicit Exclusions and Limitations

Beyond services subject to the deductible, catastrophic health plans also have explicit exclusions and limitations, meaning certain services are generally never covered by these plans, regardless of whether the deductible has been met. Routine dental and vision care, for instance, including cleanings, fillings, orthodontics, eye exams, glasses, and contact lenses, are almost universally excluded. Coverage for these services typically requires a separate, specialized dental or vision insurance plan.

Cosmetic procedures, such as elective plastic surgeries or other enhancements not deemed medically necessary for health, are also not covered. Treatments or therapies that are considered experimental or unproven by medical standards are typically excluded from coverage. This includes alternative therapies or new medical technologies that have not yet gained widespread acceptance as standard medical practice.

Non-emergency care received from providers outside the plan’s designated network may have very limited or no coverage. While emergency care is usually covered regardless of the facility’s network status, choosing out-of-network providers for non-urgent services can result in significant out-of-pocket expenses. Long-term care services, such as nursing home care, assisted living facilities, or in-home custodial care, are not covered by catastrophic health plans. Additionally, over-the-counter medications and supplies are generally not reimbursable by these plans.

Preventive Care Coverage

An important aspect of catastrophic health plans is their coverage of certain essential preventive services, which stands as a notable exception to the general rule of high deductibles. These specific services are covered at no cost to the policyholder, and this coverage applies even before the deductible has been met.

Examples of these covered preventive services include annual physical examinations, various health screenings like blood pressure, cholesterol, and certain cancer screenings, as well as routine immunizations. Contraception services are also typically covered at no cost. This upfront coverage for preventive care is a feature of ACA-compliant plans, including catastrophic plans.