Health insurance can be confusing. Often, there are many terms and phrases you may not fully understand. Fortunately, we’ve decoded some of the common healthcare terms for you to help better navigate your health insurance policy.
Coinsurance is the percentage of the cost of a medical service that you are responsible for, after meeting your deductible. For instance, if your bill comes to $100 and your coinsurance is 20%, you would need to pay $20 toward the cost.
A copay is a fixed amount you need to pay for the health-care service or supply that's already covered by your health plan. Your health plan may require a certain amount of copay for a prescription or doctor's visit, and then the plan pays the rest of the cost.
The deductible is the amount of money you pay out of pocket for healthcare services before your health insurance policy begins paying for your expenses. For instance, if your deductible is $100, you would be responsible for the entire cost of healthcare services you receive until you've paid that $100 deductible.
The essential health benefits include those healthcare services that should be covered by your policy under the Affordable Care Act. Some of these essential health benefits include hospitalization, emergency services, prescription drugs, preventative services, mental health and pediatric services, to name a few.
Health insurance plans have partnered with healthcare providers like doctors, hospitals, and other facilities to provide healthcare services to the members of the policy. These providers are called "in-network." When you receive care from in-network providers, the cost of the service will usually be lower, as your insurance plan will cover some or most of the cost.
Out-of-network providers are those medical professionals and institutions who have not entered into an agreement to provide medical services to the plan's members, which means costs for services from these providers may be more expensive than the in-network providers.
This refers to the amount you'll pay for your healthcare services. This can include a deductible, coinsurance, and copays.
The maximum out-of-pocket cost limit is the most you'll pay out of pocket over the year. After you've reached this limit, your insurance should pay 100% of the costs for all covered essential health benefits for the remainder of the year. This limit includes deductibles, coinsurance, and copayments.
Premium is the amount of money you pay each month, quarter, or year for your health insurance coverage.
Preventive care services are healthcare services designed to keep you healthy and detect diseases before they become serious. These include regular check-ups, immunizations, counseling and screening tests. Your insurance company should pay for these preventive services, without you having to pay a copayment or meeting your deductible.
The provider is the medical professional, hospital, or facility that you receive medical services from. Your insurance company has a provider network, which is a list of healthcare professionals and institutions they partner with to provide medical services to members of the plan. You should consult with your healthcare policy to find the healthcare providers that are in-network.