Un­der­stand­ing the jar­gon of health in­sur­ance

The Calvert Recorder - - Medical Guide - • Non-net­work

The world of health­care can be con­fus­ing to nav­i­gate. Be­fore the preva­lence of health main­te­nance or­ga­ni­za­tions and var­i­ous other health and well­ness in­sur­ance groups, ob­tain­ing med­i­cal as­sis­tance in­volved go­ing to the doc­tor and then pay­ing the bill. But to­day peo­ple must nav­i­gate co­pay­ments, coin­sur­ance, de­ductibles, and sav­ings plans, which can make it dif­fi­cult to un­der­stand what’s go­ing on with your in­sur­ance com­pany.

Health­care is stan­dard­ized in some ar­eas of the world and pub­licly fi­nanced with lit­tle to no out-of-pocket costs for par­tic­i­pat­ing cit­i­zens. Else­where, ac­cess to health in­sur­ance is pro­vided through em­ploy­ers or govern­ment as­sis­tance pro­grams or in­di­vid­u­ally pur­chased.

Un­der­stand­ing some health in­sur­ance-re­lated jar­gon is a great way to bet­ter ed­u­cate one­self about the in­dus­try.

• Ben­e­fit pe­riod: The ben­e­fit pe­riod re­fers to the du­ra­tion of time ser­vices are cov­ered un­der your plan. It is usu­ally a cal­en­dar year from the point of start to end. It may be­gin each year on an an­niver­sary date when you first re­ceived cover­age.

• Coin­sur­ance: This is a per­cent­age of the cost of ser­vices ren­dered in spe­cific ar­eas out­lined by the health plan that you are re­spon­si­ble for af­ter a de­ductible is met. For ex­am­ple, a plan may cover 85 per­cent of costs, with pa­tients re­spon­si­ble for the re­main­ing 15.

• Co­pay­ment (co­pay): A co­pay­ment re­fers to the flat rate you pay to a provider at the time you re­ceive ser­vices. Some plans do not have co­pays.

• De­ductible: The amount you pay for health ser­vices be­fore the in­sur­ance com­pany pays. You must meet a set limit, which varies by plan and provider, be­fore in­sur­ance will kick in and cover the re­main­ing costs dur­ing the ben­e­fit pe­riod. Many plans have a $2,000 per per­son de­ductible. This de­ductible re­news with each cal­en­dar year.

• HMO: A health main­te­nance or­ga­ni­za­tion of­fers ser­vices only with spe­cific HMO providers. Re­fer­rals from a pri­mary care doc­tor of­ten are needed to see spe­cial­ists.

• HSA: A health sav­ings ac­count en­ables you to set aside pre-tax in­come up to a cer­tain limit for cer­tain med­i­cal ex­penses.

• Long-term care in­sur­ance: A spe-

cific health­care plan that can be used for in-home nurs­ing care or to pay for the med­i­cal ser­vices and room and board for as­sisted liv­ing/nurs­ing home fa­cil­i­ties.

• Net­work provider: This is a health­care provider who is part of a plan’s net­work. Many in­sur­ance com­pa­nies ne­go­ti­ate set rates with providers to keep costs low. They will only pay out a greater per­cent­age to net­work providers.

provider: A health­care provider who is not part of a plan’s net­work. Costs may be higher if you visit a non-net­work provider or if you are not cov­ered at all.

• PPO: A pre­ferred provider or­ga­ni­za­tion is a type of in­sur­ance plan that of­fers more ex­ten­sive cover­age for in-net­work ser­vices, but of­fer ad­di­tional cover­age for out-of-net­work ser­vices.

Nav­i­gat­ing health in­sur­ance is eas­ier when pol­icy hold­ers un­der­stand some com­mon in­dus­try jar­gon. Metro Creative

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