We all know the health insurance industry is full of jargon and fancy terminology. It’s so hard to find out what you’re looking for when browsing their website, right? The impression of many people on these websites dedicated to this niche is that their contents are so convoluted with the terms they use.
In order to provide you with a clearer understanding of your health insurance coverage, we’ve taken the time to explain some people as among the most confusing insurance terms in ordinary speech. Before you sign up for health insurance, see to it that you understand the following words to their core. We encourage you to save this glossary of health insurance jargon for later use.
Coinsurance. Following the completion of your deductible, you will be responsible for coinsurance payments for health care. Consider the following example for better understanding: If you have a $100 medical bill, assuming your coinsurance contribution is 20%, you will settle $20 for medical care if your deductible has been met.
Copays. These are preventative measures designed to keep the healthcare system free from overuse and abuse. They establish accountability for individuals getting treatment while also preventing them from overspending on personal policies, rather than ones determined solely by insurance coverage.
The average copay has increased to around $15 in recent years, but it varies significantly depending upon where you live as well as what type of plan(s) or package options were selected when signing up at the time of enrollment.
Important Health Benefits. This is a compilation of healthcare services that should be included in plans offered through the Marketplace for Health Insurance under the Affordable Care Act. There are a variety of services offered, including emergency care, hospitalization care, mental health, newborn care and maternity care, wellness and preventive programs, prescription medicines, and pediatric services.
Deductible. Prior to your health insurance plan assisting you with payment for health care services, you may have to pay yourself out of pocket for services. The health insurance plan won’t pay anything unless you pay your deductible of $100.
In-network. This is a group of hospital institutions together with their trained doctors, and other health care providers with whom a health insurance plan has negotiated to provide healthcare and treatment to plan members. These service providers are known as “in-network providers.”. Sometimes they are called “network providers. You can confirm with your insurance health plan provider if you want to verify if your physician is in-network.
Out-of-network. These are the various hospital institutions, medical professionals, surgeons, neurologists, physicians and other providers of health care services that are not commissioned by a health insurance provider to offer healthcare and treatment services to plan members. They are considered out-of-network. If you use a provider who is not part of the network, you may be charged extra.
Out-of-Pocket Costs. These are the expenses you are accountable for, the money you spend on health care services. Your out-of-pocket expenditures may include your copays, deductibles, and coinsurance.
Out-of-pocket Limit. The maximum amount you will spend during a policy year (often one year) before your plan begins to cover 100% of eligible Essential Benefits. This ceiling must encompass copayments, deductibles, and coinsurance but not premiums. In 2016, the highest out-of-pocket expense limit for an individual policy is $6,850 and for a family plan, it is $13,700.
Premium. This is the sum of money you need to pay your insurance provider each month after you sign up for the health insurance plan they have on offer. Depending on your selected terms of payment, they are payable weekly, quarterly or annually.
Preventive Care. The aim of preventive care is to ensure your health before sickness strikes. Routine checkups, immunizations, patient counselling, screening tests, fall into this category. In-network clinicians must deliver these services free of charge under insurance plans. You can’t be charged a Coinsurance or Copayment, even if you still have an outstanding deductible.
Provider. This can either be a medical professional or an organization that provides various services for health care. Examples of which include hospitals, pharmacies, surgeons, and physicians. Verify if your physician is part of your health insurance plan’s network or not.
Provider Network. This is the network of physicians, hospitals, and other providers in the healthcare industry that joined forces with your insurance plan provider to offer treatment to the plan’s members. Do some research if you want to find out if a particular provider is included in your health insurance plan. An HMO’s provider network may be smaller than that of a PPO, depending on your specific plan type (HMO or PPO).