Insurance 101 |
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| Co-Insurance: | ||
This is the percentage of you bill you are responsible for after you have met your deductible and before you have reached your maximum out-of-pocket. 80/20 Co-insurance is the most common co-insurance. Many companies offer 70/30 or 60/40 coinsurance to lower your premium. |
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| Copay: | ||
This is the cash you pay the time of service. Your copay may or may not be your total charge for the service. Your copays are in addition to your plan deductible and maximum out-of-pocket. |
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| Deductible: | ||
The amount of out-of-pocket you have to pay each year before your health plan kicks in and starts paying for services. |
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| Doctor Copay: | ||
Usually $25, $30 or $35 depending on the plan you choose. Once you pay your copay, the remainder of you charges for that visit is paid at 100%. Lab work and x-rays done in your doctor’s office are not included in your copay. |
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| EOB: | ||
Explanation of benefits. |
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| E/R Copay: | ||
Some plans have and E/R copay in addition to your deductible and co-insurance. |
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| Facility Copay: | ||
| This is rare but some plans have a facility copay in addition to your deductible and co-insurance. | ||
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| H.S.A.: | ||
| Health Savings Account. | ||
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| Maximum Out of Pocket: | ||
| This is the total of your deductible and co-insurance that you must meet before the company pays 100% of your bills. Your dedctuble $500 plus co-insurance $2000 equals your annumal maximum out-of-pocket or $2500. Your maximum out-of-pocket maybe more important than your deductible. A $2500 deductible 100% plan (no co-insurance) has a maximum out-of-pocket of $2500 dollars. This is the same as the $500 deductible 80/20 to $10,000. Your premium is much lower with the $2500 deductible 100% plan and your maximum out-of-pocket (exposure) is the same. | ||
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| Pre-existing Condition: | ||
A condition – medical or physical – which was present and for which medical advice, diagnosis, care or treatment was recommended or received within the 6 month period ending on your effective day. Pregnancy is considered a pre-existing condition. |
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| Premium: | ||
The amount of money you pay on a regular basis – once a month, four times a year, twice a year, or once a year – to the insurance company to keep your health plan active. You can’t apply what you pay towards your premium towards your deductible. |
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| Prescription Copay: | ||
Most prescription cards are copay driven. You have different copay for generic, preferred brand and non-preferred brand drugs. |
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| Underwriting: | ||
| All companies look at your age, height/weight, tobacco use, history of medical conditions, current medical conditions, and medications to determine if you are eligible for coverage, if your premium needs to be rated up to cover conditions. Some companies rate up for health conditions and medications. Some companies issue exclusion riders (will not cover the condition) depending on the company you apply with, your condition can be 1. rated up 2. ridered out or 3. you can be denied cover due to medical conditions. | ||
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