Understanding Health Insurance
The Key Terms you may want to know to understand health insurance
Preventative Care: Care that keeps you healthy such as annual exams, vaccinations, pap smears, related lab work, etc. Preventative Care is covered 100% on almost all plans (short-term plans do not cover preventative care). This is never subject to deducible.
Office Visits: The copay that you are responsible for when you go to the doctor (visits not related to preventative care).
Urgent Care: The copay you pay when going to the Urgent Care Center
Emergency Room: The copay you pay when you go to the emergency room; this may also be subject to deductible. The copay may be waived if you are “admitted.”
Prescription Drugs: How your prescription drugs are covered, usually organized by different copays corresponding to different tiers. Common tiers are: generic, brand, non-formulary brand. You can usually go to the health carrier’s website and look at their drug formulary to find out what tier your drug will fall into.
Outpatient Care: The care you receive for treatment without being admitted to a hospital.
Inpatient Care: The care you receive for a treatment in the hospital, such as a surgery requiring admission into the hospital or overnight stays.
Deductible: What you pay before your plan starts to cover you. This usually only applies to certain services, not all services on your plan. Some examples of deductible services are: lab work, inpatient coverage, surgeries, etc).
Co-Insurance: The percentage the plan will pay after your deductible has been met. You will pay the remaining percentage. For example, if the plan pays 80%, you pay 20%.
Out of Pocket Maximum: The most you pay out of your own pocket towards expenses on a plan. This is your deductible + your co-insurance maximum (the most you will pay). For plans that started in 2014 (and beyond), all copays will also count toward the out of pocket maximum.
**Deductibles and out of pocket maximums typically start over every calendar year or every plan year depending on your plan.
Durable Medical Equipment: Often referred to as DME. This is medical equipment such as a wheel chair, crutches, etc.
Disclaimer: Please note that the definitions listed are not to be used for legal purposes. They are for informational purposes. Information may be subject to change. For final information or exact definitions please refer to your certificate of coverage and plan benefits.