DEFINITIONS
Co-Insurance
After the deductible is met, a percentage of the claims are shared by the insured (you) as well as the insurance company until the out of pocket maximum is met for the year. Under our H.S.A plan, where it states 100%, that means that the insurance company pays 100% and you do not pay another penny after the out of pocket maximum is met, for example.
Co-Pay
A payment made by the insured (you) in addition to that made by the insurance company. These are usually smaller amounts such as $10, $20, $50 or even $300 for more expensive services. The insurance company picks up the rest of the bill.
Deductible
A specified amount of money that the insured (you) must pay before an insurance company will pay a claim.
Dependent
Anyone that you cover under your insurance, in addition to yourself. This could be your spouse, child(ren), or family (spouse AND children). Dependent age limit for a child is age 26.
EOB (Explanation of Benefits)
Paperwork that the insurance company sends to the insured (you) directly after services are performed. This paperwork is important! It will tell you exactly what the services cost, what the insurance company paid, what you paid, and how much of what was paid was applied towards your annual deductible.
H.S.A (Health Savings Account)
A tax-advantaged medical savings account available to only employees covered under the qualifying high-deductible health plan (HDHP) labeled H.S.A. The funds contributed to an account are not subject to federal income tax at the time of deposit. Both the employee and the employer typically contribute to these accounts. The account belongs to the insured (you) forever, and all unused funds roll over from year to year. There are maximum contribution limits for the year, which are set by the IRS. As long as the funds are only ever used for qualifying medical expenses, they will never be taxed. It is kind of like a medical only 401(k) that you can use before and during retirement.
In-Network
Any doctor, hospital or other facility that is considered a preferred provider of the insurance carrier. All carriers provide lists of these doctors and they should always be used whenever possible.
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.
Out-Of-Network
Any doctor, hospital or other facility that is NOT a preferred provider of the insurance carrier. If an insured chooses to use an out of network facility for any reason, you will be charged more for these services and the carrier will pay less of the total cost incurred. All efforts should be made to avoid out-of-network doctors and facilities.
Out of Pocket Maximum
The most an insured (you) have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan covers 100% of the costs of covered benefits
Physician Services
Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
PPO (Preferred Provider Organization)
A medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced or “discounted” rates. These “preferred providers” are considered “in network”, so the coverage for using these in network doctors or facilities will be less than if you decide to use an “out of network” doctor. These plans are made up of Co-Pays, Deductibles, and Co-Insurance.
Pre-Authorization
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. Pre-authorization is not a promise your health insurance or plan will cover the cost.
Premium
The amount the insured (you) pays to have the insurance. Similar to the premium you pay for home insurance, life insurance or vehicle insurance, premiums are not reimbursable nor are they used to pay for any part of the costs incurred with the benefit.
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.
