Does health insurance terminology seem like a foreign language to you? Does your mind go blank when you hear words like co-pay, deductible, and out-of-pocket expenses? If you’re nodding your head in agreement, welcome to the club. There are many other people like you who are confounded by insurance and treat it like it’s a necessary evil. However, if you’re letting the insurance company or your medical provider dictate your insurance coverage because you don’t understand your policy, you might be depriving yourself of benefits or coverage you’re entitled to receive. Knowing your insurance policy and its terminology is an advantage you do not want to ignore since it could cost you some precious dollars and possibly medical care.

A simple way to look at health insurance terminology would be to separate it into two categories: 1) Costs; and 2) Medical Coverage. Familiarizing yourself with the vocabulary used in your policy will help you to understand your financial obligations and coverage rights. In fact, starting with the following ten terms might provide you with enough insight to help you manage your health coverage more effectively.

Need to Know Costs

  • Premium – The amount paid for insurance coverage. A premium can be paid monthly or quarterly, or even annually, depending on the preference of the policy owner. The premium is separate from the out-of-pocket expenses such as deductible, coinsurance, and annual out-of-pocket maximum
  • Deductible – The amount paid by the policy owner for a medical service covered by an insurance policy. After the deductible is reached (for example, $6,000 for a single person), the insurance company pays an agreed portion of each expense; until the out-of-pocket amount is reached. Keep in mind that the deductible amount affects an insurance premium. The inverse relationship results in higher the deductible, the lower the premium; the lower the deductible, the higher the premium.
  • Coinsurance – Percentage of covered services that the policy owner and insurer pay. Coinsurance is applied after the annual deductible is has been met. For example, our $6,000 deductible with an out-of-pocket maximum of $7,400, you receive a $ 23,000 hospital bill. Insurance negotiated rate is $8,000. You pay the first $6,000 (deductible). Coinsurance may be 80/20- so the insurer would pay the next $1,600 (80% of remainder), and you would pay $400 (20% of remainder, after deductible).
  • Co-Payment – A fixed dollar amount paid for an in-network covered service. Examples of co-pays include the fee paid for a doctor appointment ($35 for specialist) and prescriptions ($10 co-pay).
  • Annual Out-of-Pocket Maximum – The maximum amount of money paid by the insured over a policy year. The expenses applied usually include copayments, deductibles, and co-insurance. Once met, all covered in-networkservices should be paid by the insurer at 100% for the remainder of the calendar year.

Need to Know Coverage

  • Referral – Necessary with HMO coverage to obtain from Primary Care Physician to see a specialist, have an MRI, and to receive other services.
  • Preauthorization – The primary care doctor or specialist submits a request to the insurance company for preauthorization for certain medical services (MRI, time in a hospital, etc.). Although issued by the insurance company; it still does not guarantee they will pay for the service. However, failure to obtain one in a non-emergency situation (say you have an MRI at your doctor’s office which did not obtain the necessary preauthorization) could make you responsible for up to 100% of the procedure’s cost.
  • Exclusion or Limitation – Exclusion refers to services or supplies the insurance company will not approve; for example, cosmetic plastic surgery may be a policy exclusion. A limitation is a similar clause, setting forth exceptions to coverage, with specific qualifications. Traditionally, limitations are in connection with PRE-EXISTING CONDITIONS. If you have an: “Obamacare” policy you need not worry about these while the Affordable Care Act is law. PLEASE read these clauses CAREFULLY—they can have disastrous results.
  • Denial – Refusal by the insurance company to approve a service or pay a claim.
  • Allowed Amount – Agreed upon amount an insurance company will pay a provider for specified medical services or supplies.

Informed Decision-Maker

 When you are an informed decision-maker, you are better prepared to make smart choices regarding medical care and insurance options. You will be taking care of yourself and your family members health, finances, provided you manage your insurance benefits wisely. However, despite best efforts, sometimes we need assistance. With medical matters, seeking assistance from patient advocates like Human Health Advocates leverages expertise in areas including insurance benefits, medical billing (including hospitals bills), and health insurance coverage denials.

Human Health Advocates, LLC, located in Boca Raton Florida, serves clients both statewide and throughout the nation. It is a very favorably reviewed entity and accredited by the Better Business Bureau with an A+ Rating. Its members are Board-Certified Patient Advocates who specialize in medical debt reduction. If you are having difficulty understanding or managing your medical bills and/or health insurance Explanation of Benefits (EOB’s), reach out and contact one of our Board-Certified Patient Advocates. We review medical bills and health insurance determinations to locate errors in providers’ charges and processing.  We prepare insurance appeals for denied claims. We negotiate reductions in your medical debt from hospitals and other medical providers. If you have problems with your medical bills or health insurance, get in touch. WE CAN HELP!

By Human Health Advocates