When it comes to choosing insurance, there are many options, which can be confusing. On top of a variety of options, there are multiple complex terms involved that can make selecting the best plan for your needs challenging. We get it! That’s why we exist! Our expert team of licensed agents are here for you; we are dedicated to simplifying a complex market. Our mission is to bring accessible and affordable insurance to all Americans.
Whether or not you decide to use iCan for your insurance needs, we want to be sure you understand the most common terms involved with selecting a health insurance plan. In this blog post, we have created a mini-glossary of some of the “big words” used in the health insurance world. Remember, not all insurance plans are created equally. The key is to align your needs with your budget to ensure the coverage you are purchasing – allows for the healthcare that you will more than likely be seeking.
Health Insurance Terminology 101
CHIP (Children’s Health Insurance Program): CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers pregnant women. Each state offers CHIP coverage and works closely with its state Medicaid program.
Co-Pay: A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
Coinsurance: Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
Deductible: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
HMO (Health Maintenance Organization): HMO stands for health maintenance organization. With an HMO plan, you pick one primary care physician. All your health care services go through that doctor. That means that you need a referral before you can see any other health care professional, except in an emergency. Visits to health care professionals outside of your network typically aren’t covered by your insurance.
Medicaid: Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.
Medicare: Medicare is the federal health insurance program for:
- People who are 65 or older
- Certain younger people with disabilities
- People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)
Network: A provider network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to its members. These providers are called “network providers” or “in-network providers.” A provider that hasn’t contracted with the plan is called an “out-of-network provider.”
Network Provider/In-network Provider: To help you save money, most health plans provide access to a network of doctors, facilities, and pharmacies. These doctors and facilities must meet certain credentialing requirements and agree to accept a discounted rate for covered services under the health plan in order to be part of the network. These health care providers are considered in-network.
Non-network Provider/Out-of-network Provider: A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
Open Enrollment: The yearly period when people can enroll in a health insurance plan. Open Enrollment for 2019 runs from November 1, 2018, to December 15, 2018.
Outside of the Open Enrollment Period, you generally can enroll in a health insurance plan only if you qualify for a Special Enrollment Period. You’re eligible if you have certain life events, like getting married, having a baby, or losing other health coverage.
- Job-based plans may have different Open Enrollment Periods. Check with your employer.
- You can apply and enroll in Medicaid or the Children’s Health Insurance Program (CHIP) any time of year.
Out-of-pocket Limit: The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
PPO (Preferred Provider Organization): PPO stands for preferred provider organization. PPO plans give you flexibility. You don’t need a primary care physician. You can go to any health care professional you want without a referral—inside or outside of your network. Staying inside your network means smaller co-pays and full coverage. If you choose to go outside your network, you’ll have higher out-of-pocket costs, and not all services may be covered.
Point-of-Service (POS) Plans: POS plans let you get medical care from both in-network and out-of-network providers. If you have a POS plan, you’ll choose a primary doctor from a list of participating providers. Your primary doctor can refer you to other network providers when needed. If you want to visit an out-of-network provider, you’ll also need a referral and you may pay higher out-of-pocket costs.
Premium: The amount that must be paid for your health insurance or plan. You usually pay it monthly.
Short-term Insurance: Short Term medical insurance, also called Temporary health insurance or Term health insurance, can provide a temporary solution to help fill gaps in coverage. It is basically ideal for when you are stuck in a coverage gap.
- Between jobs
- Waiting for other coverage to begin
- Waiting to be eligible for Medicare coverage
- Without health insurance, outside of Open Enrollment
- H. (2018). Children’s Health Insurance Program (CHIP) Eligibility Requirements. Retrieved 2018, from https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program/
- C. (2018). Glossary of Health Coverage and Medical Terms. Retrieved 2018, from https://www.cms.gov/CCIIO/Resources/Files/Downloads/uniform-glossary-final.pdf
- U. (2018). Home. Retrieved 2018, from https://www.uhc.com/individual-and-family/short-term-health-insurance/what-is-short-term-health-insurance
- M. (2018). Medicaid. Retrieved 2018, from https://www.medicaid.gov/medicaid/index.html
- H. (2018). Open Enrollment Period – HealthCare.gov Glossary. Retrieved 2018, from https://www.healthcare.gov/glossary/open-enrollment-period/
- C. (2018). Understanding Provider Networks. Retrieved 2018, from https://www.cigna.com/individuals-families/understanding-insurance/provider-networks
- C. (2018). What You Should Know About Provider Networks. Retrieved 2018, from https://marketplace.cms.gov/outreach-and-education/what-you-should-know-provider-networks.pdf
- M. (2018). What’s Medicare? Retrieved 2018, from https://www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare
- B. (2018). What’s the difference between HMO and PPO plans? Retrieved 2018, from https://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works/difference-hmo-ppo.html