Because our agency makes sure that you and your family have the right Health coverage, you don't necessarily have to know all the esoteric terms related to it. However, it makes sense to be a knowledgeable consumer. That's why we've compiled this list of key Health insurance-related definitions for you. Learn more about coverage rules at Understanding the Affordable Coverage Act and Health Insurance.
Key Health insurance terms
- Balance billing. A bill for the difference between what your insurer will pay and what the physician charges for a service.
- Coinsurance. The amount that you're required to pay for medical care in a fee-for-service plan after you've met your deductible. The co-insurance rate is usually expressed as a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.
- Deductible. The amount of money you must pay each year to cover your medical care expenses before your insurance starts paying.
- Exclusions. Specific conditions or circumstances for which the policy will not provide benefits.
- Maximum out-of-pocket cost. The largest amount of money you will be required to pay a year for deductibles and coinsurance. It's a dollar amount set by the insurance company, in addition to regular premiums.
- Preexisting condition. A health problem that existed before the date your insurance coverage became effective.
- Primary care physician (PCP). A PCP monitors your health, diagnoses, treats minor health problems, and refers you to specialists if another level of care is needed. The PCP is often a family physician or internist; however, some women prefer to use their gynecologist.
- Provider. Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.
The next time you come in for a visit (or discuss your Health coverage with your employer) you'll be able to show off your knowledge. If you want to review plan options or tax-advantaged accounts, see Understanding Health Savings Accounts and Insurance.
Frequently Asked Questions
What is the difference between a deductible and coinsurance?
A deductible is the amount you pay before insurance starts to cover services; coinsurance is the percentage you pay after the deductible is met. Both affect your out-of-pocket costs for care.
What does balance billing mean for patients?
Balance billing occurs when a provider bills you for the difference between their charge and what your insurer pays; in-network providers typically prevent this practice.
Are preexisting conditions excluded from coverage?
Policies vary: some plans limit or exclude coverage for preexisting conditions while others cover them immediately; check plan terms or ask your insurer for details.
How does the maximum out-of-pocket limit work?
Once you reach that annual dollar limit for deductibles and coinsurance, the plan generally pays 100% of covered services for the remainder of the year.