Adulting 101: Health Insurance Terminology

These are some common terms that you may come across in your journey to signing up for health insurance. Take a look and let me know if you want any more info on any of them…I’d be happy to help! 🙂

Benefit year/benefit period: the time frame in which your benefits will cover you. I signed up for 2017 benefits, and my benefit period for 2017 is January 1, 2017 to December 31, 2017. If I choose not to renew my benefits (say I get married and go on my husband’s), my benefits will run out on December 31, 2017. If I choose to continue with my insurance company, my deductible and other values will reset on January 1, 2018.

Claim: a request by a patient or medical provider/hospital to the patient’s insurance company for payment of services.

Coinsurance: after you pay your deductible, most plans will have you pay a coinsurance until you reach your out of pocket maximum. The coinsurance means that you will be assigned a percentage to pay for all costs, and the insurance company will pay the rest. Typically, you will pay 10-50% and the insurance company covers the rest; it depends on your plan and what the company offers you.

Copayment: This is a flat fee that your insurance company assigns for certain services: a visit to your primary care doctor (PCP) may be $0 for an annual check up but $10 per sick visit; ER visits might cost you $100, but an urgent care center might only be $40.

Deductible: This is the amount you have to pay out of pocket for 100% of what insurance doesn’t automatically cover. For example, if you go to your PCP for a migraine and she gives you a flu shot, the migraine visit will probably be considered a “sick visit” and cost you a co-pay, but the flu shot itself will be paid for by insurance.

Dependent: If you have a spouse or child that you will pay for insurance to cover, they are your dependent.

Explanation of Benefits: A typically long-winded, but very informative read that your insurance company sends to let you know exactly what they will and will not cover/do for you.

In-network provider: If your insurance company has a preferred hospital system attached to it, this will probably be their “network.” If you go to providers in this network, you may have to pay less or have a lower deductible to meet each year than if you go to providers outside this system, or out-of-network.

Out of Pocket Maximum: This is the absolute maximum you will have to pay per benefit period. After you reach this amount, your insurance will cover 100% of everything. Unless you have hospitalizations each year, it will probably be really hard to meet this amount.

Hope this helps a little with your journey! Good luck!




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