HEALTH INSURANCE TERMS TO KNOW

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1 HEALTH INSURANCE TERMS TO KNOW

2 Premiums A premium is a fixed dollar amount that will stay the same each month whether you use the doctor a lot or don t go to the doctor at all that month. It is what you pay to your insurance company each month to have health insurance coverage. For example: To continue my insurance coverage I pay the company $150 each month. This might come in the form of a bill online or the employer might take it out of your check every pay period.

3 Claim A claim is just a fancy word for bill for health care services that your doctor submits to the insurance company for payment. Health insurance claims actually begin before you even make an appointment. The insurance company is responsible only for paying for things that are covered under your policy, so it s important to find from your insurance company what they cover beforehand so you aren t shocked by the costs. Usually you will pay a portion (e.g co-payment or co-insurance) of each claim at your visit and your doctor will send the rest of your bill to your health insurance claims processing center. After the insurance claims process center gathers the relevant information from your doctor they will cover everything the policy covers or inform you about what the policy doesn t cover and what you then owe for the visit. If they do not cover those services, you are responsible for the balance.

4 Cost-sharing Cost sharing is what you do with your insurance company through deductibles, co-insurance, and co-payment. Your insurance pays part of your bills and you pay part of your bills, thus sharing the cost of your medical expenses.

5 Deductible A deductible is a fixed amount of money you have to pay before most, if not all, of the policy s benefits can be enjoyed. However, in many health insurance policies you can use some services, like a visit to the emergency room or a routine doctor s visit without meeting deductibles first. Another way to think about deductibles is an amount you pay towards certain medical expenses before your plan starts paying a share of the costs. Some plans have lower deductibles such as $500, while other plans have higher deductibles, such as $2,000.

6 Co-payments A dollar amount that does not change that you pay every time you receive a medical service. For example: you go to the doctor and the receptionist will have you pay a $25 co-pay. Then the rest of your bill will be covered by the insurance company as long as the services (e.g. appointment, labs etc) is a covered by the policy.

7 Co-insurance A percentage of your medical bill that does not change that you pay every time you receive a medical service. For example,: your co-insurance might be 20% of every claim (bill). Co-insurance is the percentage you will pay for your services after you ve met the deductible. It shares the cost between you and your health insurance plan for example: if you pay 20%, your plan pays the other 80% of the bill. You pay co-insurance until you meet your total out of pocket maximum for the year.

8 Co-Insurance vs Co- Payment So what s the difference again between Co-Insurance and Co-payment? The amounts are different because co-payment is a set dollar amount, while co-insurance is a set percentage of the overall medical bill. For example: Let s say your medical bill for a visit is $250. The person with the co-payment would pay $25 while the person with the co-insurance would pay $50 (aka 20% of $250).

9 Referral A written order from your primary care doctor for you to see a specialist to get medical services that your doctor may not provide. For example, psychological services, cardiovascular care, infectious diseases specialists, and other services.

10 Specialist A doctor that focuses on a specific area of medicine to diagnose, manage, and treat certain types of medical conditions. This includes cardiologists, neurologists, infectious disease doctors, and others.

11 Dental Insurance Survival Terms

12 Waiting Period A time period in which the dental plan will not pay for services, leaving the client responsible for 100% of any costs during this time period. This is a one-time wait period occurring when someone first signs up with a plan. The reason for a waiting period is to prevent people from buying dental insurance only when they have a lot of dental procedures that they want to get covered and then canceling their insurance after the work is completed. for example: say Mary needs a crown. She contacts her insurance company to see if the procedure will be covered and learns that since she s only had her plan for 3 months she has no coverage for that procedure. She finds out that any crown procedures have a 6 month waiting period under her dental plan, so she will need to wait another 3 months before it is covered. A dental insurance waiting period can also be used as a way to curb dental insurance costs. The longer the dental insurance waiting period, the lower the dental insurance premium will be.

13 Annual Maximum The maximum amount that a dental plan will pay for services in a plan year (usually January through December, but it depends on your plan). The patient is personally responsible for paying costs above the annual maximum. for example: David went to the dentist and found out he had two cavities that needed filling. But, his dental insurance plan would only cover one cavity before his annual maximum would be met. David s dentist explained he could either pay for the second cavity out of pocket or she could schedule one filling for December and the other for January when David s annual maximum would reset.

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