my smart choice health insurance guide©...sample health insurance plans – summary of benefits...
TRANSCRIPT
My Smart Choice Health Insurance Guide©
• Why should I want health insurance?
• Why is this important?
• What do I need and want?
• What are my choices?
• How much can I afford?
• How much will it cost?
http://extension.umd.edu/insure/consumer-resources
For use during the Spring 2013 project pilot testing
Welcome to this guide.
Are you like most consumers?
You dread making decisions about health insurance.
You are not really sure if you should purchase health
insurance.
You don’t really understand the terms and provisions of
health insurance.
Maybe you’re not confident that you know enough to make
a smart choice.
Don’t worry. This guide was created just for you. We’ve shown you
the big questions to ask. We’ve provided a definition of important
words to know and sample plans to study.
We’ve included 3 worksheets to help you—
1. Identify your needs and wants
2. Compare health insurance plans
3. Prepare a spending plan
You will then be able to—
• Ask key questions • Make sense of answers • Use simple tools to choose • Pick out smart choices • Feel good about your choice
Created by Bonnie Braun, Extension Specialist on behalf of the
University of Maryland Extension Health Insurance Literacy Team. 4-3-13
My Health Insurance Needs Worksheet
SECTION 1: MY FAMILY’S DOCTORS VISITS
1) Do we have a general practitioner(s)? Yes No
2) Do we see any specialists? Examples: Allergist, OBGYN, eye doctor? Yes No
3) How many times did my family and I visit the doctor? Please fill in the chart below. Extra rows are provided for you in case you have a larger family.
You and your family’s annual wellness visit or physicals, done by your general practitioner, are now covered 100% with no out-of-pocket costs to you! Please keep that in mind when filling out this chart and do not include them in this calculation.
Person Doctors Seen Health Condition Treated
How Often Doctor(s) Seen
Me
Spouse/Partner
Child
Child
Below is a chart to figure out how often you and your family visits the doctor. Fill in the appropriate circle or if your number of visits isn’t shown, fill it in on the blank provided.
4) If we see specialists, how many different specialists do we see? +
5) About how many times did we each visit our general practitioner (outside of annual wellness visits/physical) in the past year?
+
6) About how many times did we visit specialists in the past year? +
7) In the past year, how many times did we go to urgent care? +
8) In the past year, how many times did we go to the emergency room?
+
9) I need to purchase insurance for how many people (You, spouse/partner, and child/children)?
+
Note: Use this section to help fill out the “My Health Insurance Policy Comparison Worksheet”
My Health Insurance Needs Worksheet
SECTION 2: MY FAMILY’S PRESCRIPTIONS
9) Do we take any prescription medicines (those prescribed by Yes No
a doctor and NOT the ones I buy over-the-counter at a store)?
I can use this chart to figure out what prescription medicines my family and I take and how much they cost.
I take: How often do I get refills? How much do I have to pay?
Example: Rhinocort Once a month $20
My spouse(partner) and/or Child(ren) take:
How often do they get refills? How much do I have to pay?
My total cost each year $
Note: Use this section to help figure out “My Health Insurance Policy Comparison Worksheet”
SECTION 3: CHANGES IN HEALTH CARE NEEDS
10) Is there anything coming up in the next 12-18 months that I Yes No
didn’t have to plan for last year? Note: Use this chart to think about new health situations we may have to plan for in the next
12-18 months.
New item I will have: What kind of insurance coverage will I need?
Does this mean I will need more or less coverage?
Example: I want to have a baby
Obstetrics and gynecology, hospital stay, prenatal medicine
More
Example: Child turning 27 Can’t be covered anymore on my insurance
Less
Early Retirement Can’t be covered by employer insurance
More
Overall, do I need more or less coverage for next year?
My Health Insurance Needs Worksheet
SECTION 4: COVERING HEALTH CARE COSTS
Please refer to “My Health Insurance Spending Plan Worksheet” to calculate your health care costs.
SECTION 5: PRIORITIZING MY HEALTH INSURANCE NEEDS
15) Based on my answers, I want to be sure to pay attention to these items when choosing an insurance plan (and there may be several of these that apply to my situation). To help identify the best plan for me and my family, I would rank from 1 (most important) to 6 (least important) the following :
The expected changes in health care needs that will happen to me and/or my family in the next
12-18 months.
The doctors my family and I see are included in the network of the health insurance plan.
The medicines that my family and I need are covered by the insurance.
The cost of insurance on a monthly (or annual) basis (this would be the premium).
The amount of out of pocket costs including emergencies, deductible, co-pay or co-insurance.
NOTES:
Created by
Virginia Brown, Extension Educator and Teresa McCoy, Assistant Director, University of Maryland Extension Maria Pippidis, Extension Educator, University of Delaware Extension,
Health Literacy Insurance Initiative Team
University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national
origin, marital status, genetic information, or political affiliation, or gender identity and expression.
For use during the Spring 2013 project pilot testing
University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national origin, marital status, genetic information or political affiliation, or gender identity and expression.
For use during the Spring 2013 project pilot testing. Turn over to next page
Sample Health Insurance Plans – Summary of Benefits
Sample 1 - EPO Sample 2 - POS Sample 3 - PPO
Sample Plan Overview In-network only In-network Out-of-network In-network Out-of-network Deductible: None - individual
None - Family
None - Individual None - Family
$125 Individual $250 Family
None - Individual None - Family
$125 Individual $250 Family
Out-of-Pocket maximum: None - individual None - Family
$500 - Individual $1,000 - Family
$1,500 - Individual $3,000 - Family
$500 - Individual $1,000 - Family
$1,500 - Individual $3,000 - Family
Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited National Network Yes No, Regional Yes Yes Yes Primary Care Physician Required Yes Yes No No No
Common and Preventive Services Primary Care Physician Office visit $15 copay $15 copay 70% of allowed benefit
after deductible
$15 copay 70% of allowed benefit after deductible
Specialist Office visit $30 copay $30 copay 70% of allowed benefit after deductible
$30 copay 70% of allowed benefit after deductible
Adult Physical Exams 100% of allowed benefit 100% of allowed benefit Not covered 100% of allowed benefit 70% of allowed benefit after deductible
Well Baby/Child Visits 100% of allowed benefit 100% of allowed benefit Not covered 100% of allowed benefit 70% of allowed benefit after deductible
Immunizations and Vaccines covered 100% of allowed benefit 100% of allowed benefit 70% of allowed benefit after deductible
100% of allowed benefit 70% of allowed benefit after deductible
Emergency Treatment Urgent Care $30 copay $30 copay 70% of allowed benefit
after deductible
$30 copay 70% of allowed benefit after deductible, plus
$30 copay Emergency Room Services $75 copay for ER facility
plus $75 copay for ER Physician services
$75 copay for ER facility plus $75 copay for ER
Physician services
$75 copay for ER facility plus $75 copay for ER
Physician services
$75 copay for ER facility plus $75 copay for ER
Physician services
$75 copay for ER facility plus $75 copay for ER
Physician services
Ambulance Services – Emergency Transport 100% of allowed benefit 100% of allowed benefit 100% of allowed benefit 100% of allowed benefit 100% of allowed benefit Hospital Services
Inpatient care 100% of allowed benefit 90% of allowed benefit 70% of allowed benefit after deductible
90% of allowed benefit 70% of allowed benefit after deductible
Hospitalization 100% of allowed benefit 90% of allowed benefit 70% of allowed benefit after deductible
90% of allowed benefit 70% of allowed benefit after deductible
Outpatient Surgery 100% of allowed benefit 90% of allowed benefit 70% of allowed benefit after deductible
90% of allowed benefit 70% of allowed benefit after deductible
University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national origin, marital status, genetic information or political affiliation, or gender identity and expression.
For use during the Spring 2013 project pilot testing. Turn over to next page
Sample 1 - EPO Sample 2 - POS Sample 3 - PPO Women’s Services In-network only In-network Out-of-network In-network Out-of-network
Well Woman Visits 100% of allowed benefit 100% of allowed benefit Not covered 100% of allowed benefit 70% of allowed benefit after deductible
Mammography (Preventive) 100% of allowed benefit 100% of allowed benefit 70% of allowed benefit after deductible
100% of allowed benefit 70% of allowed benefit after deductible
Maternity Benefits 90% of allowed benefit 90% of allowed benefit 70 % of allowed benefit after deductible
90% of allowed benefit 70% of allowed benefit after deductible
Other Services and Supplies Diagnostic Lab & X-Ray 100% of allowed benefit 90% of allowed benefit 90% of allowed benefit 90% of allowed benefit 70% of allowed benefit
after deductible
Durable Medical Equipment 100% of allowed benefit 90% of allowed benefit 70% of allowed benefit after deductible
90% of allowed benefit 70% of allowed benefit after deductible
Vision Services and Supplies Vision – Routine Exam – up to $45 (once
every plan year) Prescription lenses, frames, contact lenses -$200 every
12 months
Exam – up to $45 (once every plan year)
Prescription lenses coverage varies on type,
frames – up to $45, contacts - coverage
varies on type
Exam – up to $45 (once every plan year)
Prescription lenses coverage varies on type,
frames – up to $45, contacts - coverage
varies on type
Exam – up to $45 (once every plan year)
Prescription lenses coverage varies on type,
frames – up to $45, contacts - coverage
varies on type
Exam – up to $45 (once every plan year)
Prescription lenses coverage varies on type,
frames – up to $45, contacts - coverage
varies on type
Source: State of Maryland Guide to Your Health Benefits, March 2013
Sample Health Insurance Plans – Summary of Benefits
Sample Monthly Health Insurance Premiums Sample Insurance Plan 1 person 2 people 3+ people
Sample 1 – EPO $375.00 $772.00 $ 947.00 Sample 2 - POS $390.00 $702.00 $ 975.00 Sample 3 – PPO $454.00 $817.00 $1134.00
Section 1: Health Insurance Plan/
Policy Costs
Option 1
Option 2
Option 3
Monthly premium amount
$_____ per month x 12 months= $_________
$_____ per month x 12 months= $__________
$_____ per month x 12 months= $_________
How much is
your copay or
coinsurance?
Use the
estimated
number of
visits from the
My Health
Insurance
Needs
Worksheet to
complete this
section.
General Office Visit:
$_______ per visit
X ____ visits =
$_______
$_______ per visit
X ____ visits =
$ _______
$_______ per visit
X ____ visits =
$_______
Hospital visits:
$_______ per visit
X ____ visits =
$_______
$_______ per visit
X ____ visits =
$_______
$_______ per visit
X ____ visits =
$_______
Specialists:
$_______ per visit
X ____ visits =
$_______
$_______ per visit
X ____ visits =
$_______
$_______ per visit
X ____ visits =
$_______
Dental:
$_______ per visit
X ____ visits =
$_______
$_______ per visit
X ____ visits =
$_______
$_______ per visit
X ____ visits =
$_______
Total estimated costs on copay/ coinsurance (Add up your estimate for each in this section).
$
$
$
My Health Insurance Comparison Worksheet
This worksheet will help you compare three health insurance options. Use the health insurance information provided to you by the insurance company to fill in the worksheet. Call the insurance company for more information if you can’t find the answers in their written papers. Use the information you calculated in Section 1 of the My Health Insurance Needs Worksheet to help estimate costs in Section 1 of this worksheet.
Important Words to Know
Health Plan - is a benefit
your employer, union or
other group sponsor
provides to you to pay for
your health care services.
Health Insurance Policy–
is for people who aren't
connected to job-based
coverage. Individual health
insurance policies are
regulated under state law.
Premium– the amount that
must be paid for your
insurance policy.
Copayment- the amount
you pay for a health service.
Coinsurance- your share of
costs of a covered service,
calculated as a %, of the
allowed amount for the
service. You pay this plus
any deductibles you owe.
Specialist -A specialist is a
doctor who focuses on a
specific area of medicine or
a group of patients to
diagnose, manage, prevent
or treat certain types of
symptoms and conditions.
2
Prescription drug costs
Is the cost of prescriptions covered?
Yes No If yes, $ per prescription x number of prescriptions filled
Yes No If yes, $ per prescription x number of prescriptions filled
Yes No If yes, $ per prescription x number of prescriptions filled
Does the plan/policy
cover your
prescriptions? (Find
out by checking
online or by calling
the company; ask about
the formulary)
Yes No
Yes No
Yes No
My total yearly
estimated costs on
prescriptions:
$
$
$
Vision
Total yearly estimated
costs for vision
$ premium $ per visit X visits
Out-of-Pocket Costs $ lenses $ frames
$ premium $ per visit X visits
Out-of-Pocket Costs $ lenses $ frames
$ premium $ per visit X visits
Out-of-Pocket Costs $ lenses $ frames
My estimated yearly
costs for vision
$
$
$
How much is the annual deductible?
Hospital Visit
$
$
$
Medical Care:
$
$
$
Prescriptions:
$
$
$
My estimated yearly
deductible costs $
$
$
What is the yearly out- of-pocket limit? Does it include the deductible?
$
Yes No
$
Yes No
$
Yes No
Total Estimated Yearly Health Care Costs
Add up all the green
boxes to calculate the
total out of pocket
costs for each option
$
$
$
Important Words to Know
Out-of-Pocket Costs -
Your expenses for medical
care that are not paid by
your insurance policy. Out-
of-pocket costs include
deductibles, coinsurance,
and copayments for
covered services plus all
costs for services that
aren't covered in your
health insurance policy.
Deductible- amount you
owe for covered health
services before your health
plan begins to pay.
Out of Pocket Limit—The
most you pay during a
policy period (usually a
year) before your health
insurance policy begins to
pay 100% of the allowed
amount. This limit never
includes your premium,
balance-billed charges or
health care your health
insurance policy doesn’t
cover. Some health
insurance policies don’t
count all of your
co-payments, deductibles,
co-insurance payments,
out-of-network payments or
other expenses toward this
limit.
3
Section 2: Accessing Medical Services Option 1 Option 2 Option 3
Do I have to take a health questionnaire to get the insurance? Yes No
Yes No
Yes No
Do ALL my providers (doctors, hospitals, specialists,
pharmacies, etc.) take this insurance? (Look on the company’s
website or call)
Yes No
Yes No
Yes No
Can I choose my medical service providers?
Yes No
Yes No
Yes No
Do I need referrals for specialists?
Yes No
Yes No
Yes No
Do I need pre-approval for medical procedures?
Yes No
Yes No
Yes No
Does this insurance accept the doctor’s billing or do I have to
pay upfront and get the insurance company to reimburse me?
Accept
Pay up front
Accept
Pay up front
Accept
Pay up front
If I have a pre-existing condition, will the health insurance
plan/policy cover me? (As of January 1, 2014 all health insurance will cover pre-existing conditions with few exceptions).
Yes No
Yes No
Yes No
What type of insurance plan/policy? POS— Point of Service—A plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. May require you to get a referral from your primary care doctor in order to see a specialist. PPO— Preferred Provider Organizations—A plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network but can use doctors, hospitals, and providers outside of the network for an additional cost. HMO— Health Maintenance Organization—A plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out -of-network care except in an emergency. May require you to live or work in its service area to be eligible for coverage. Often provide integrated care and focus on prevention and wellness. EPO— Exclusive Provider Services— A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
POS
PPO
HMO
EPO
POS
PPO
HMO
EPO
POS
PPO
HMO
EPO
My Health Insurance Comparison Worksheet
Important Words
to Know
Referral - is a special kind
of pre-approval that health
plan members must
obtain from their primary
care physician before
seeing a specialist.
Pre-approval- decision by
your health insurer that health care service,
treatment plan,
prescription drug or
durable medical
equipment is medically
necessary. Sometimes
called pre-authorization,
prior approval or
pre-certification.
Pre-existing condition-
A condition, disability or
illness (either physical or mental) that you have
before you're enrolled in a
health insurance plan/ policy.
4
Section 3: Coverage
Option 1
Option 2
Option 3
This plan/policy covers these services (Covered essential and other services):
Note: Include coverage for any family
members. Check for services you and your
family use now or expect to use, including
prescriptions, maternity, mental health, etc.
This plan/policy does NOT cover these services
(Excluded services):
Note: Include coverage for any family
members. Check for services you and your
family use now or expect to use, including
prescriptions, maternity, mental health, etc.
What would be the costs associated with
these services not covered by Insurance?
$
$
$
Are any treatments or care specifically excluded?
What events are considered “approved emergency room vi sit ” events?
Are maternity benefits covered?
Is there a waiting period on maternity
benefits and how long is it?
If so, how long:
If so, how long:
If so, how long:
Are there any special limits or exclusions on
maternity benefits?
Are there pre-approval requirements for
hospital admission?
Will you qualify for coverage under
COBRA if your job ends?
Important Words to
Know
Covered Essential
Services –essential
benefits include:
emergency services,
hospitalizations, laboratory
services, maternity care,
mental health and
substance abuse
treatment, outpatient or
ambulatory care, pediatric
care, prescription drugs,
preventive care,
rehabilitative and
habilitative services, vision
and dental care for
children.
Approved Emergency
Room visits—types of
visits that will be covered
by insurance. Non-
emergency use of
emergency room will
typically not be covered by
insurance.
COBRA -A Federal law
that may allow you to
temporarily keep health coverage after your
employment ends, if you
lose coverage as a
dependent of the covered
employee, or another
qualifying event. If you
elect COBRA coverage,
you pay 100% of the
premiums, including the
share the employer paid,
plus a small
administrative fee.
5
Section 4: Other Considerations
Option 1
Option 2
Option 3
If I travel, does this plan/policy cover care
outside my local area?
Yes No
Yes No
Yes No
Does this plan/policy have coordination of benefits with other health insurance?
Yes No
Yes No
Yes No
Is this insurance plan/policy authorized to do
business in my state? (To find out, call your
state’s Insurance Commissioner’s Office).
Yes No
Yes No
Yes No
Does the company have a high number of
consumer complaints? (To find out, call your
state’s Insurance Commissioner’s Office).
Yes No
Yes No
Yes No
My Health Insurance Comparison Worksheet
Important Words
to Know
Coordination of
Benefits -
coordination of
medical services
between medical
providers OR
coordination of
insurance coverage
between insurers.
Adapted by
Maria Pippidis, Extension Educator, University of Delaware Extension,
Virginia Brown, Lynn Little and Mia Russell, Extension Educators, University of Maryland Extension
for the Extension Health Insurance Literacy Initiative
from the Washington State Office of the Insurance Commissioner and the University of Missouri Making Money Count Curriculum, Chapter 7.
University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation,
physical or mental disability, religion, ancestry, or national origin, marital status, genetic information, or political affiliation, or gender identity and expression.
For use during the Spring 2013 project pilot testing.
Utilities
Electric Heating oil or gas Trash/garbage Water and Sewer Sewer Telephone Cable TV Internet Cell phone Other Total
Food
Groceries Food away from home School lunches Other Total
Transportation
Car/truck payment Car Insurance Maintenance/repairs Gasoline, oil, etc. Other Total
Personal
Clothing Personal Care Tobacco/alcohol Total
Family Care
Child Care or other dependent care
Personal Allowances
Total
Health and Medical
Insurance premium (not deducted from paycheck)
Insurance copay(s)/ co-insurance costs
Prescriptions Over-the-counter medications
Vision Dental Health Savings Acct Total
Educational Expenses
Tuition Sports and organizational fees
School supplies Total
Pet Care
Pet food Pet supplies Veterinary services Pet care (grooming, boarding, etc.)
Total Entertainment
Movies, books, etc Vacation Hobbies, etc. Total
Gifts & Charitable Contributions
Gifts for others Charitable contributions
Total
Credit Payments
Credit Card # 1 Credit Card # 2 Credit Card # 3 Personal loan payments
Total Periodic Expenses
Expenses that come up once or twice a year. Fill in the estimated costs under the month they are due. Add your total and divide by 12 to determine the monthly portion.
Jan Feb Mar Apr May June July August September October November December Subtotal Subtotal ÷12 = Monthly portion of periodic expenses
Deductions taken from your paycheck:
Federal taxes State taxes FICA Social Security Medicare Insurance Premiums:
Life insurance Health Insurance Disability Insurance
Flexible Spending Acct
Retirement Savings Other Savings (payroll deduction)
Other deductions Total deductions
Housing
Rent or Mortgage Insurance (Homeowner/Renters)
Property taxes Maintenance/repairs
Total
Monthly Income (Gross pay before
deductions)
Wages/salary #1 Wages/salary #2 Other sources:
Total Income
Expenses:
My/Our Monthly Spending Plan Worksheet
SUMMARY
Total Monthly Income
Total Monthly Expenses
University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental
disability, religion, ancestry, or national origin, marital status, genetic information, or political affiliation, or gender identity or expression.
For use during the Spring 2013 project pilot testing
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Glossary of Health Coverage and Medical Terms Page 1 of 4
Important Words I Need to Know
Glossary of Health Coverage and Medical Terms • This glossary has many commonly used terms, but isn’t a full list. These terms and definitions are intended to be
educational and may be different from the terms and definitions in your plan. Some also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See Summary of Benefits & Coverage for information on how to get a copy of your policy or plan document.)
• Bold blue text indicates a term defined in this Glossary.
• See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation.
Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)
Appeal A request for your health insurer or plan to review a decision or a grievance again.
Balance Billing
Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example,
to pay. For example, if your deductible is $1000,
Jane pays 100%
Her plan pays 0%
if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30.
your plan won’t pay anything until you’ve met
(See page 4 for a detailed example.)
A preferred provider may not balance bill you for covered services.
Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed
your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
amount for the service. You pay co-insurance
Jane pays
20%
Her plan pays
80% Emergency Medical Condition plus any deductibles you owe. For example,
(See page 4 for a detailed example.) An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid
if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non- emergency caesarean section aren’t complications of pregnancy.
severe harm.
Emergency Medical Transportation Ambulance services for an emergency medical condition.
Emergency Room Care Emergency services you get in an emergency room.
Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
Glossary of Health Coverage and Medical Terms Page 2 of 4
Excluded Services Health care services that your health insurance or plan doesn’t pay for or cover.
Grievance A complaint that you communicate to your health insurer or plan.
Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of
inpatient and/or outpatient settings.
Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Home Health Care Health care services a person receives at home.
Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Hospital Outpatient Care Care in a hospital that usually doesn’t require an overnight stay.
In-network Co-insurance
Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Non-Preferred Provider A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out- of-network co-insurance usually costs you more than in- network co-insurance. Out-of-network Co-payment A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co- payments usually are more than in-network co-payments.
Out-of-Pocket Limit The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed
The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who
amount. This limit never includes your premium,
Jane pays
0% Her plan pays
100%
contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network
balance-billed charges or health care your health
(See page 4 for a detailed example.)
co-insurance.
In-network Co-payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
Physician Services Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Glossary of Health Coverage and Medical Terms Page 3 of 4
Plan A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
Premium The amount that must be paid for your health insurance
or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications.
Prescription Drugs Drugs and medications that by law require a prescription.
Primary Care Physician A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary Care Provider A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
Provider A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Rehabilitation Services Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient
and/or outpatient settings.
Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.
UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
How You and Your Insurer Share Costs - Example Jane’s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000
January 1st
Beginning of Coverage
Period
December 31st
End of Coverage Period
Jane pays
100%
Her plan pays
0%
more
costs
Jane pays
20%
Her plan pays
80%
more
costs
Jane pays
0%
Her plan pays
100%
Jane hasn’t reached her $1,500 deductible yet Her plan doesn’t pay any of the costs.
Office visit costs: $125 Jane pays: $125 Her plan pays: $0
Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit.
Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60
Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year.
Office visit costs: $200 Jane pays: $0 Her plan pays: $200
Glossary of Health Coverage and Medical Terms Page 4 of 4