Understanding common health insurance terms

Common health insurance terms explained

When it comes to health insurance, my mom should have an honorary PhD. It came by way of the school of hard knocks, literally. Our family of five has seen cracks in arms, legs and skulls; surgery on knees and toes, eyes and a heart; concussions and stitches; colds, flu and the occasional virus that knocked us down.

If there’s a silver lining to having so many trips to the hospital, it’s that you begin to understand health insurance.

Mom pored over health insurance statements, also known as the explanation of benefits. She researched terms, asked questions and demanded answers to her billing questions for what was paid, to whom and why. Most of that research was done without the internet.

Because many of today’s health care consumers don’t have the tenacity of my mom, I asked Kristi Speers, Banner Health Network’s payer account program director, for help. Speers outlined insurance terms and steps to take to so you might one day earn your own honorary PhD in health care consumerism.

Speers said to start by using your insurance to stay well. Take advantage of benefits your plan offers to keep you and your family healthy whether that’s gym membership discounts, wellness programs or screenings that are paid for under your plan. Staying healthy saves money.

Next, understand key terms to better navigate the health insurance world.

  • Co-payments. These are fixed-dollar amounts that you pay to see a provider. This can apply to a primary care visit, specialist visit, urgent care visit or other service and they vary in amount.
  • Deductible. This is the amount you have to pay before your insurance begins to pay. They call it an “out-of-pocket” expense because this is the cash coming out of your pocket. If you insure your family, the health plans usually only require that three family members reach their deductible. Once that happens, all other family members will show up on your insurance as having met their deductibles, too.
  • Co-insurance. This is the percentage of charges covered by your insurance that you have to pay.
  • Out-of-pocket max. This is the total you have to pay on your own before your insurance starts to pay at 100 percent of the covered charges. You can have a family out-of-pocket max, which is the total amount that your pay on your own before the health plan covers 100 percent of charges for the family.
  • Network. Your network is the physicians, hospitals, clinics and other providers that have contracted to offer medical services with your health plan. A physician or hospital may be in network or out of network. If you go to a physician that is out of network, expect to pay more out of your own pocket for services with that provider.
  • Out-of-area coverage. You will want to know what care your plan covers if you are out of your service area. Plans will typically pay for urgent and emergency care. If you have a student attending college out of the area, make sure you learn if there are providers in that area who can offer routine care.
  • Primary Care Provider (PCP). It is important to select a Primary Care Provider and have an establishing visit with that provider so you have someone who can care for you when you are sick or have health concerns. This provider can offer guidance and referrals if you need specialized care. Not all health plans require that you name a PCP, but doing so can benefit the health of you and your family. Make sure the person you want to see is taking new patients before you sign up with an insurance plan.
  • Specialist. If you see any specialists for specific illnesses or injuries, make sure those providers are part of your network. If they are not, you can ask your PCP for a referral to an in-network provider. It doesn’t hurt to ask a provider if he or she would consider joining a health plan. However, the process can take many months. Plus, depending on its needs, a health plan network may or may not accept a provider.

This basic information can get you started learning about health insurance. In this case, knowledge is health. Good consumers stay involved and ask questions to make good decisions.

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