If you’re considering purchasing health insurance, you may feel overwhelmed by the variety of terminology associated with it. From coinsurance to deductibles, there are numerous health insurance terms you should know before you enroll. But don’t worry; we’ve got you covered. We have translated some of the confusing terminologies around health insurance into plain English to help you better understand your health insurance coverage.

Let’s dive in.

Coinsurance

Coinsurance is a health insurance term that refers to the percentage of the cost of a healthcare service that you are responsible for paying after you have met your health insurance plan’s deductible. 

For example, if your healthcare bill is $1,000 and you have already met your deductible, and your coinsurance is 20%, you will be responsible for paying $200 (20% of $1,000), while your insurance company will pay the remaining $800. Coinsurance is one of the ways in which health insurance companies share the cost of healthcare services with their policyholders.

Copay

Copay refers to a fixed amount of money that you may need to pay out-of-pocket for a covered healthcare service or supply. For example, your health plan may require a $20 copay for an office visit or a $10 copay for a generic prescription. After you pay the copay, your health insurance plan will cover the remaining cost of the healthcare service or supply. 

Copays are a way for health insurance companies to share the cost of healthcare services with their policyholders. Copay amounts may vary depending on the type of healthcare service or supply, and the specifics of your health insurance plan.

Deductible

A deductible is the amount of money that you need to pay out-of-pocket for healthcare services before your insurance plan starts covering those services. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of healthcare services you receive during the year before your plan starts contributing to the cost of covered services. Once you’ve met your deductible, your insurance plan will begin to share the cost of healthcare services with you. The amount of the deductible can vary depending on the specifics of your insurance plan and is an important factor to consider when choosing a plan, as it can significantly impact your out-of-pocket costs for healthcare.

Essential Health Benefits

Let’s talk about Essential Health Benefits – a set of healthcare services that must be covered by plans in the Health Insurance Marketplace, as required by the Affordable Care Act. These benefits include emergency services, hospitalization, maternity and newborn care, mental health, prescription drugs, preventive and wellness services, pediatric services, and more. 

In-Network Providers

Understanding the difference between in-network and out-of-network providers is critical. In-network providers are a group of doctors, hospitals, and other healthcare providers that your health insurance plan has partnered with to provide care to its members. 

Out-of-Network Providers

When you receive healthcare services from a provider that has not partnered with your insurance plan to provide care to its members, this is known as an out-of-network provider. It’s important to note that using an out-of-network provider may result in additional costs for you, so it’s crucial to know which providers are in-network before receiving care.

Another important term to be familiar with is out-of-pocket cost, which refers to the amount you pay for health care services. This may include your deductible, coinsurance, and co-pays.

The out-of-pocket maximum is the most you’ll pay in a policy period, usually one year, before your plan starts to pay 100% of the covered Essential Health Benefits you receive. This limit must include deductibles, coinsurance, and co-payments, but typically does not count premiums toward your out-of-pocket maximum.

Monthly Premiums

Monthly premiums refer to the regular payments that an individual pays to their health insurance company in exchange for coverage. This payment can be made on a monthly, quarterly, or yearly basis depending on the insurance plan. 

The amount of the premium varies based on a number of factors, such as the type of coverage, the individual’s age, location, and the level of benefits they choose. It’s important to understand the cost of the monthly premium when selecting a health insurance plan, as it can impact your budget and overall financial health.

Preventative Care

Preventive care is health care services focused on keeping you healthy before you may become sick. These include routine check-ups, patient counseling, screening tests, and immunizations. Plans must offer these services at no cost to you when the services are provided by in-network doctors. This means they can’t charge a copayment or coinsurance, even if you haven’t met your deductible for the year.

Provider

Lastly, it’s important to understand what a provider is. This refers to a person or place you go to receive health care services. Examples include doctors, hospitals, pharmacies, and more. Check with your health insurance plan to find out if a provider is in-network or out-of-network.

By familiarizing yourself with these health insurance terms, you can better understand your coverage and make an informed decision when choosing a health insurance plan.

Still Have Questions?

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