Most health insurance policies also offer something similar to a cheat sheet that describes the insurance coverage and covers the most common medical services. However, you should be sure you understand the different things that are excluded by your plan. Many health insurance plans to offer services such as mental health , chiropractic services and health benefits at work. Even physical therapy and health care at home often to a certain limited number of visits per year.
Co - payment or Co - wage
A copayment is a predetermined amount to be paid to a medical provider for a particular type of service. For example , you may have to pay a $ 15 fee when you visit your doctor. In this case, you pay $ 15 a doctor's office at the time of the visit. Normally, you do not have to pay more - your insurance company will pay the rest . However, in some cases, if your insurance policy for specific health, may be responsible for a co - payment, a percentage of the remaining balance will be applied.
deductible
The deductible is the amount of medical expenses that you must pay before the insurance company begins to pay health benefits. Most health insurance plans have a deductible per calendar year so in January of each year the new requirement deductible. Therefore, if your deductible for the calendar year is $ 1,500, provided that the medical expenses for the current year does not exceed $ 1,500 the insurance company pays nothing for this year. Once January starts the new year, we must begin to pay for $ 1,500 of your medical expenses .
coinsurance
Coinsurance ( or out -of-pocket ) is the amount or percentage of each medical expense that you must pay . For example , you may have a medical fee of $ 100. Your health insurance company will pay 80 % of the load and are responsible for 20% increase . 20 % is the amount of your coinsurance .
Coinsurance amounts throughout the year. If you have a lot of medical expenses in a year, you can meet the requirement of the maximum coinsurance for your policy. At this time, all covered expenses are paid at 100 % for the remainder of the calendar year.
Stop loss or pocket spending limit
Sometimes the limit out of pocket expenses will hear referred your stop loss to or coinsurance . Basically , this is the amount you must pay out of pocket each calendar year before the health insurance company pays everything 100 %.
You will need to check your policy because many of the policies that require co - payments do not allow these copayments to go to the amount of his own pocket. For example, you may have reached your maximum out of pocket expenses for the year , so if you are admitted to the hospital, you pay nothing . However, since you have to pay a fee of $ 15 each time you visit the doctor , you still have to do this.
The maximum lifetime benefit
This is the maximum amount that the health insurance company will pay your medical expenses for the duration of his contract. Generally , this amount is in the millions of dollars. Unless you have a serious illness , you probably do not exhaust this amount.
Preferred Provider Organization
A Preferred Provider Organization (also known as PPO) is a group of medical providers that participants agreed to work with the company health insurance at a reduced price . It's a win - win for both parties . The insurance company has to pay less money and suppliers receive automatic references.
In most health insurance policies , you will see the different levels of benefits depending on whether you visit a participating or non- participating provider . A PPO plan offers more flexibility for the insured , as they can either visit a participating provider or non-participating . They just get a better price if they use a participant.
Maintenance Organization Health
A Health Maintenance Organization ( also known as an HMO ) is a health insurance plan that limits the specific medical providers. In general , unless you are outside the area of your network, no benefits are payable if you you go to a nonparticipating physician . In general , you should choose a doctor who will be your primary care physician ( PCP). Whenever you have a health problem , you should visit the doctor. If they feel it is necessary , they may refer to another network provider . However, you can not decide on their own to see a specialist , you must go through your PCP.
medically necessary
You see this in the insurance policies , and is a common cause of rejected applications . Most insurance companies do not cover all the costs that do not appear to them medically necessary. The fact that you and / or your doctor thinks something medically necessary, your health insurance company can not. For this reason, you should always check that the costly procedures that you are considering will be covered.
routine treatment
Routine treatment is generally defined as prevention services. For example , an annual physical exam she has on a regular basis is generally considered routine . Many vaccines that children and adults receive fall into this classification. Some insurance companies offer limited coverage for routine treatment , others provide no benefit at all.
pre-existing conditions
A preexisting condition is a condition that you have purchased and / or received treatment prior to the effective date of your insurance policy current health . The health insurance companies vary in how they handle pre -existing conditions. Some companies will not give you any coverage if you have any pre-existing chronic diseases. Others give you a blanket , but will not provide benefits for a period of time - usually 12 to 24 months. However, other health insurance policies specifically exclude pre-existing condition and never provide benefits for this condition.
Make sure you are very clear about the boundaries of their policy so it is not an unpleasant surprise when you visit your doctor.
Explanation of Benefits
This is the way the health insurance company sends you after you have finished processing your request. In him the bill they received and how they treated him detailed . Commonly called an EOB .
Coordination of Benefits
If you are eligible to receive benefits under more than one health insurance plan , its various health insurance companies coordinate benefits . This ensures that you pay no more than 100 % of the total load . There are many variations on how this can happen. Overall, the company made its first principal payment. Then he drops a copy of the charges with the junior company with a copy of the Explanation of Benefits ( EOB ) from the main company. The business school usually takes the rest of the bill.
Participating Provider
A participating provider is a health professional who has signed a contract with a health insurance company or health insurance network to ask predetermined rate for patients who are in the network.
nonparticipating provider
A non-participating provider is a provider of health care that does not have a contract with a company or network of individual health insurance . If you use a nonparticipating provider , you usually pay a larger portion of the bill . In some cases , you may be responsible for the entire bill .
Limited benefit plans
These comprehensive plans are not considered health insurance . Instead , they provide very specific and limited benefits for different types of services . For example , they may offer a fixed amount for each day of their stay in the hospital or pay a small fee for each transaction that make you fee.
Usually sold to people who can not afford or can not obtain a wider coverage due to pre - existing conditions health. Or, you can send to people who have high deductible plans . The good thing about these plans is that they generally pay in addition to any other coverage you may have. Therefore, coordination of benefits is not required.
If this is your only coverage , be aware that you will usually have to pay a large part of any bill limiting these plans typically pay large amounts per day. For example , it can cost $ 1000 per day to stay in the hospital. If your limited benefit plan that pays $ 200 per day for each day spent in hospital , you will be personally liable for the balance of $ 800 per day.
Medicare supplement plans
People with Medicare often choose to purchase a Medicare supplement plan Medicare generally does not cover medical expenses in full. Medicare continues to change and add new options, but in general , a supplemental plan pays the balance of medical expenses after Medicare pays its share. For example , most Medicare supplements collect the insurance deductible .
Some policies also pay part of the costs not covered by Medicare . There are many variations of different policies . If you're not sure what you buy, consider contacting an agent that helps the elderly.
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