Understanding health insurance and the health industry is much easier if you recognize some of the basic terminology and how it applies to you and your health insurance policy. If you have a health insurance plan and aren’t sure how it works or what the terminology means, take a few minutes to read the explanations below. Knowing these terms and what they mean to you can greatly aid you in dealing with your health care providers, insurance company, insurance agent, or during the health benefits shopping process.
This is the 12-month period in which your benefits are calculated. Most insurance companies use a CALENDAR year, which is January 1 to December 31, but a few will use a 12 month period from when your policy goes into effect. For example, if your insurance goes into effect on June 1, the END of your benefit year is May 31. Make sure that you understand how your benefit year will be calculated.
Deductible means the amount of money you must pay out of your pocket for medical expenses EACH YEAR before your health insurance begins paying out. Deductibles are usually reset to 0 at the beginning of each calendar or benefit year. Many insurance companies offer health plans that have benefits that are not subject to having to meet your deductible each year such as doctors office visits, immunizations, wellness or routine exams, etc. An easy way to remember what this term means and how it works is this:
When you have incurred medical expenses, all bills must be sent to the insurance company. When the insurance company looks at your bills, they then look at your policy and see how things are covered. They will then add up what the combined medical expenses have been for the year to date: determine what your deductible is and how much you have already paid towards meeting your deductible for the year, and pay out according to how your insurance policy says it will.
So in a nutshell, the insurance company is “deducting” your financial responsibility for medical expenses each year from the total combined medical expenses before they have any responsibility to pay out…hence the term “deductible”.
A co-pay is an amount that is paid by the patient to a provider at the time of service. It will either be a flat fee (like $15 or $20) or it can be a percentage of the service provided. The percentages or fee may vary depending on the type of service provided. A co-pay is different than “coinsurance” – see next.
Coinsurance is the percentage paid by the insurance company after you pay the deductible. Example: Your health insurance pays 70%, you pay 30%. The insurance company pays 70% coinsurance, you pay 30% coinsurance. Most health insurance policies will have a limit on the amount of coinsurance you have to pay out each year this is known as your “Annual Coinsurance Maximum” or “Stop-loss”.
Annual Coinsurance Maximum
After paying your deductible and after paying your coinsurance (classically 20% or 30% of medical expenses) to a certain dollar amount, your health insurance will pay 100% for the remaining costs in the calendar year. Example: After you pay your deductible, your health insurance pays 70% of medical expenses and you pay 30%. Once you reach the coinsurance maximum, you no longer pay 30% of the medical expenses because the insurance pays 100%.
Out of Pocket Maximum or Stop Loss
Stop Loss is the maximum amount of money you will have to pay out of your pocket in the benefit year.
This is the limit of the money the health insurance will pay out over your lifetime. Most major medical health insurance policies will be a $2 million lifetime maximum, while others will go as high as a $12 million lifetime maximum. In general, it is not recommended to have a policy with less than a $2 million lifetime maximum.
When you visit a doctor in their office they normally bill the health insurance company for an “office visit.” Most health insurance plans pay office visit expenses at the coinsurance (generally 70% or 80%) after the deductible. Some health insurance plans pay office visit expenses at the coinsurance rate but waive the deductible, which means you don’t have to reach the deductible amount before they will cover their portion of the expense. Still other health insurance plans pay office visit expenses in full after a co-pay (usually $25 or $30). It should also be noted that office visits can be classified in two different categories. One category is usually called “Routine Care,” “Wellness visits” or “Preventative care” (see definition below). The other type of office visit is deemed as “Medically Necessary” (see definition below). Certain health insurance policies cover each of these types of visits differently and other plans do not cover them at all. If having these types of office visits covered by your health insurance policy is important to you, make sure you let your agent know so that they can help find the right plan for you.
Preventive Care is classically defined as routine exams, immunizations, well child care, and cancer screenings. These include your yearly exams and checkups for things such as physicals, pap smears, mammograms, etc. Not all plans cover preventive care. It may not be a wise use of your money to have preventative care included in your plan if you never go to the doctor. A good health insurance agent can help you determine if this is necessary coverage for you.
These are the visits utilized for your smaller ailments such as colds, flu, ear infections or minor accidents. Not all plans cover ‘medically necessary’ visits, so make sure you know if your policy includes these exams if you need them covered. You may consider purchasing accident insurance or adding a rider (explained below) to your policy to cover these types of issues.
Diagnostic Lab and X-Ray
These are tests involving laboratory or imaging services (such as x-ray, CAT scan, etc.) to diagnose a health problem. These services are usually paid at the coinsurance (typically 70% or 80%) after the deductible.
When you visit a chiropractor for spinal manipulation or other services, these expenses are customarily paid at the coinsurance rate (70% or 80%) either after the deductible is met, or by waiving the deductible. Most health insurance plans limit the number of chiropractic visits/services to 10 or 12 per year – especially if the deductible is waived. After this, additional visits are not paid by the health insurance plan, and you will be responsible for the full amount of the bill.
Inpatient or Outpatient Care
When you receive care from a hospital (inpatient or outpatient services), these expenses are customarily paid at the coinsurance rate (70% or 80%) after the deductible has been met.
When you receive care from a hospital emergency room, these expenses are customarily paid at the coinsurance level (70% or 80%) after the deductible. Most health insurance plans also require you to pay an additional co-pay (commonly $75-$100) for each emergency room visit. A number of plans waive this additional co-pay if you are actually admitted to the hospital through the emergency room and the plan will pay as an inpatient service. A plan can sometimes be structured to have separate coverage for accidents as an additional rider (see definition below) to your policy.
Prescription medications can be classified as generic, brand name, or non-preferred brand name (see below for definitions). Please Note: Not all health insurance plans pay for prescription drugs, so if you already take prescription drugs or think you will need help in the future with prescription drugs, you will want to make sure that you are purchasing a plan that includes this coverage. Prescription drugs may be covered at the coinsurance rate (70-80%) after a deductible specifically for prescription drugs is met, other plans may include Prescription drugs in the total deductible for the plan.
Drug manufacturers are permitted to sell a generic version of a medication after the patent expires for the brand name medication (generally 20 years after the brand name medication was registered). Generic medications are equivalent to the corresponding brand name medication, but are much less expensive than the brand name medication. Health insurance plans frequently provide better payment for generic medications as an incentive for you to ask for the generic version. About half of all prescription medications filled in the United States are filled with generic medications.
Brand Name Medications
Brand name medications are more expensive than generic medications. Most health insurance plans create a limited list of brand name medications that they will pay for and many health insurance plans also provide less coverage for brand name medications than for their generic counterparts.
Non-Preferred Brand Name Medications
Most health insurance plans create a limited list of brand name medications they will pay for. If your brand name medication is not on this list, it might be paid at a lower level under “Non-Preferred Brand Name Medications.”
Some health insurance plans cover the cost of maternity, which includes doctor and hospital charges for prenatal care as well as labor and delivery. Maternity is expensive to add into a health insurance policy because it is considered a “guaranteed expense” for the insurance company. If a woman becomes pregnant, it is a safe bet that there is going to be medical expenses incurred! If there are no complications and the birth goes well, the insurance company will be out a large monetary portion of the cost of delivery and even more if there are problems with the delivery or the newborn. Insurance companies price maternity so that they can still maintain profits. In some cases it may be best to save your money and pay for the prenatal care and the delivery out of your own pocket (or on a credit card) and let the insurance cover the catastrophic events. The difference you save in the monthly cost of having maternity coverage may be well worth it to you. Remember, once you have a policy that covers maternity, you can’t just remove the maternity coverage after the pregnancy is done! You will continue to pay for that maternity coverage for as long as you have that policy.
Mammography is a specific type of imaging that uses a low-dose x-ray system for the examination of breasts to detect early breast cancer in women experiencing no symptoms and to detect and diagnose breast disease in women experiencing symptoms. Current guidelines from the American Cancer Society (ACS), and the American Medical Association (AMA) recommend a screening mammography every year for women, beginning at age 40. Various plans will have automatic coverage for mammograms but some will not. Several states (like Washington State, for example) have specific guidelines that require companies to have coverage for mammograms in their policies as an automatic benefit.
Outpatient mental health services include visits to a licensed counselor, therapist, or psychiatrist. Inpatient mental health services include admission to a psychiatric hospital. Many plans do not cover mental health services.
Rehabilitation therapy may include physical therapy, occupational therapy, speech therapy, message therapy, cardiac rehabilitation, and chronic pain therapy. Most health insurance plans limit rehabilitation therapy to a certain number of visits per calendar year or to a certain dollar amount that they will pay for rehabilitation for either the year or for a lifetime.
Anything that changes the way your policy acts by default is called a “Rider”. A rider can be anything from an exclusion of coverage for a medical condition, or additional coverage for potential conditions. (As in an “accident rider” mentioned earlier in this report)
Occupational Coverage/On the job coverage
The largest portion of health insurance plans do not cover occupational related medical expenses. This can be a HUGE pitfall for self employed people. Always make sure that if you need to be covered while you are working that your plan will give you “on the job coverage”. If you get injured or sick while you are on the job and you do not have Workman’s Compensation or Labor and Industries accident coverage, you may have to pay for ALL medical expenses out of your own pocket.
Vision coverage is usually broken into two parts: vision exam, and vision hardware. Vision exam benefits include the cost of a refractive exam used to test vision acuity (20/20, 20/40, etc.). Vision hardware represents the cost of eye glasses or contact lenses. A number of health insurance plans do not cover vision exams or hardware. However, medical issues relating to the health of the eye (like Glaucoma) are almost always covered under the regular medical portion of the health insurance plan.
Each insurance company will have a list of doctors that the company has negotiated terms for payment of services with. You can go to the insurance company’s website to find a listing of contracted “preferred providers”.
This information may help you understand a policy that you already have, or aid you in understanding a policy that you may be thinking about purchasing. The more knowledge you have about what the industry “jargon” means, the more you will be able to make informed decisions about the insurance you choose to use.
By: Shad Woodman