It might as well be Greek to most non-Greek speaking health insurance consumers. How do you get a handle on this health care stuff? Hopefully we can help.
Deductibles and Coinsurance
The deductible is the amount you have to pay of your medical bills before insurance coverage kicks in. Coinsurance is the percentage you pay after the deductible is met, usually 20%.
Coinsurance Maximums and Out-of-Pocket Maximums
The coinsurance maximum is the annual limit on how much you'll have to pay in coinsurance. In other words, you may be responsible for 20% of the bill until you reach say $5,000 for example, regardless of how much the medical bill is. An out-of-pocket maximum is the most you'll have to pay for care per year. This maximum usually includes the deductible, copayments, and coinsurance. Once you meet this maximum dollar amount, your plan covers 100% of all bills for the rest of the year.
In-Network or Out-of-Network Coverage
Most contemporary health insurance plans in the United States is of the PPO type. That means you have preferred coverage with a network of doctors and hospitals. That is in-network coverage. However, you are still covered with any other doctor or hospital, but you'll pay a higher coinsurance amount, for example you may pay 50% out-of-network, when the in-network coinsurance is 20%. HMO plans typically only cover in-network medical care except for emergencies.
Negotiated Rate
The negotiated rate, or contracted rate, is the rate in-network providers have agreed to accept from your insurance company. This is probably the most underrated benefit of all health insurance coverage. The negotiated rate is sometimes just a small fraction of what someone without health insurance would pay. This is particularly true of expensive diagnostic tests like MRI exams. So lets say you are paying 20% coinsurance for that MRI exam, that means you're paying 20% of an already highly discounted rate.
Lifetime Maximum
Many health insurance plans also have a lifetime maximum, which is the total amount the plan will pay toward your medical expenses. The lifetime maximum is usually $5 million.
Office Visit Co-payments
A copayment is the fixed dollar amount of a medical bill that you'll be responsible for. For example, you may have a $30 copay for a routine trip to the doctor.
Outpatient Procedures
Outpatient procedures, like minor surgeries or colonoscopy procedures that do not require an overnight hospital stay, usually require a coinsurance rate.
Hospital and Emergency Care
A trip to the hospital emergency room or an overnight stay in the hospital will probably result in both copay and coinsurance depending on your plan. Some plans waive an ER copayment if you're admitted into the hospital for further care. Your health plan will also provide a list of inpatient medical services that are covered. An "inpatient" service is one that requires you to stay in a health facility overnight.
Maternity Care Coverage
Coverage for routine exams during pregnancy and normal delivery are not included in most health insurance plans. Maternity care can be added at extra cost. Your medical plan will cover any costs connected with non routine delivery like an emergency cesarean. So if you're looking for health insurance and you're planning on having a family, make sure you choose a plan with full maternity coverage.
Prescription Drug Coverage
If your plan includes prescription drug coverage, it will usually cover different classes of drugs differently. Generic drugs are covered with a small co-payment, brand name drugs will have a higher copay, and some drugs are not covered at all. You can find a list of covered drugs on your health plan's drug formulary list. Non-formulary drugs are not covered. Many health plans with prescription drug coverage now have a separate deductible, say $500, which applies to brand name drugs.
Get Started
The best advice we can give you is to buy your health insurance through us. Our rates are the same as if you were to purchase your health plan directly from the insurance company, because premiums are regulated at the state level. Just give us a call at (800) 557-5693 or get started on your quote online...
