These insurance terms may be useful in understanding your insurance plan.
Co-insurance: The insurer and the insured share medical costs after the deductible is met. With traditional non-managed care plans, the percentage the insured pays is based on provider charges. In managed care plans, the percentage the insured pays may be based on rates negotiated between the physician’s office and the insurance company.
Claim or Insurance Claim: A request for payment to an insurance company under the terms of the policy.
Co-payment: A flat fee paid by you for medical services, usually at the time of service. This can apply to physician office visits, prescriptions, and emergency or hospital services.
Deductible: Out-of-pocket medical expenses you must pay each year before the insurer or health plan will make payment.
Explanation of Benefit Forms (EOB) or Medicare Summary Notice (MSN): Notification from your insurance company, Medicare, or Medicaid about claim payments and patient responsibility amounts.
Health Insurance Marketplace Plans: Also known as the Health Insurance Exchange, it allows individuals and small businesses to purchase health insurance. Plans are offered in four tiers, based on premiums and out-of-pocket costs. Eligible consumers can obtain tax credits as well as connect with programs like the Children’s Health Insurance Program (CHIP).
Health Maintenance Organizations (HMOs): Organized systems for providing healthcare within a geographic area. Each HMO plan offers a set of basic and supplemental services. Members typically select a primary care physician who is responsible for making referrals to specialists when needed. HMOs offer no “out of network” benefits and have low out-of-pocket (co-pay) expenses.
Health Savings Account (HSA): Tax-free savings accounts designed to encourage savings for healthcare expenses. An HSA allows patients to have greater control of their healthcare expenditures. To take advantage of a HSA, a taxpayer must be enrolled in a high-deductible health plan.
High-deductible health plan (HDHP):An insurance plan with lower premiums, but higher deductibles than traditional health plans.
Indemnity Plans: The member chooses his or her own providers with minimal oversight of care. Out-of-pocket payments are generally a percentage of the provider’s fee schedule.
Managed Care: A broad term describing programs designed to manage the cost and quality of healthcare. Plans vary from narrow provider networks with low out-of-pocket amounts to relatively open provider networks with high out-of-pocket amounts.
Medicaid: The government health insurance program for low-income, indigent, and elderly individuals.
Medicare: The federal health insurance program for older Americans and eligible disabled individuals. Part A covers inpatient hospital or skilled nursing facility stays. Part B covers outpatient services and diagnostic testing. Part C, often referred to as Medicare Advantage Plans, allows beneficiaries to receive Medicare benefits through private health insurance plans, we strongly discourage Medicare Advantage Plans. Part D provides coverage for drug benefits.
Neither Part A nor Part B covers all medical costs. Some beneficiaries purchase Medicare Supplemental Insurance, often referred to as a Medigap plan, to cover the out-of-pocket expenses such as deductibles and co-insurance.
Coverage Gap or “Donut Hole”: Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means there’s a temporary limit on what the drug plan will cover for drugs.
Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2017, once you and your plan have spent $3,700 on covered drugs, you’re in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap.
Point of Service (POS): POS plans are similar to HMO plans. However, POS members have higher out-of-pocket (co-insurance) payments if they choose to directly seek specialists without referrals from their primary care physicians.
Preferred Provider Organization (PPO): PPOs generally provide “in-network” and “out-of-network” benefits and do not require a primary care physician referral to see a specialist. The insured’s portion of the payment is less when using an “in-network” provider.
Primary Care Physician (PCP): A physician responsible for providing primary care services and referrals for specialty care.