Health insurance has gone through substantial reforms over the past few years and will
continue to undergo changes, which can make understanding your coverage
quite confusing. However, it’s imperative to understand the basic
terminology. Once you get a grasp of the essential definitions, you’ll
be capable to comprehend and compare how various health plans will operate
based on your circumstances.
The important terms you need to know include the following:
Premium – The monthly payment to purchase the insurance. If your job offers
health insurance, your employer typically covers a portion of the premium
and the remainder can be deducted out of your payroll. If you purchase
your own health insurance, you may be entitled to premium subsidies that
cover a portion of the premiums. If you’re on Medicare, your Part
B premiums are often taken from your Social Security payments.
Deductible – The cost you must pay out of pocket prior to payments by your
insurer. It affects how much money you must pay to the doctor or hospital,
and is usually paid when treatment occurs. Depending on your plan, the
deductible may be paid once per calendar year or once per new condition.
Co-pay – A fixed dollar amount which you pay for particular services. Co-pay typically
applies to office visits, urgent care visits, prescription drugs, and
even surgeries and inpatient care.
Coinsurance – The percentage of the cost of services which you are accountable for.
When you analyze your plan description, you’ll notice some services
which display a percentage of the cost, as opposed to a copay amount.
Coinsurance applies to services which aren’t covered by a copy,
and it goes into effect once you’ve met your deductible.
Out-of-pocket maximum – The highest amount of costs you’ll have to pay for essential health
benefits for the year. You costs can derive from a combination of copays,
coinsurance, and deductible.
In-network – A group of healthcare providers and facilities who possess a contract with
your health insurance carrier. Your health plan’s regular copays,
coinsurance, deductible, and out-of-pocket maximum are only valid if you
use in-network doctors and facilities. Out-of-network care means paying
Essential Health Benefits – the healthcare services that must be covered by plans offered in the health
insurance marketplace and instates expanding their Medicaid coverage according
to the Affordable Care Act (ACA). These services include the following:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse disorder services, such as behavioral
- Prescription drugs
- Rehabilitation and habilitative services
- Lab services
- Preventive and wellness services
- Chronic disease management
- Pediatric services, such as oral and vision care
For more information, contact
Insurance Specialists, Inc. today!