The Language of Health Insurance

The Language of Health Insurance:
What Does It Mean?
By Bernice Jones

Gambling with your Healthcare Coverage
If you’re like most people, you pay your premium, hand over your insurance card, then hope for the best. STOP! You don’t have to take a risk every time you walk into the clinic or pharmacy. Deciphering what your plan covers is frustrating and confusing when you don’t know what the terms mean. Here are some of the major/most important terms broken down to help you understand.
What you pay for the coverage you recieve. This varies depending on coverage, age, location and tobacco use. It’s easy to be drawn toward the lowest number but be aware of what those plans will cost you throughout the year. Low Premiums usually result in High Deductibles which cost you more upfront. Things that help lower your premium:
-Marketplace Tax Subsidies -Employer contributions

The amount you’re responsible for BEFORE the plan starts covering you. This is a major factor in choosing the right plan for yourself. What are you comfortable paying before your plans major benefits kick in? Plans are usually set up in two ways:
Copayment Style
Copayments for set services are not subject to the deductible while while other services are deductible dependant.
Deductible Style
Deductible must be met before any service is covered.
Set payment amounts for services like physician visits, prescriptions, etc. These services are not subject to the deductible if there’s a Copayment for them in your plan. This is beneficial because you can have coverage for these things without meeting your deductible. Keep in mind, ONLY the consultation at the physician’s office is included so you are billed for any extra services like x-rays or laboratory testing.

The percentage you pay for service AFTER the deductible is met.
Example: Policy with 20% Coinsurance with deductible met: X-ray cost $200-80%=$40 patient responsibility.
Example: Same policy with deductible not yet met: X-ray cost $200=$200 patient responsibility.

Maximum Out of Pocket (MOOP)
The most you will pay annually. It’s the “Worst Case Scenario” part of your plan. When reached, coinsurance stops and you’re covered at 100%.
Example: Sadies policy has a $2,000 deductible, 20% coinsurance, and a MOOP of $6000. She breaks her leg and has surgery. Her medical bills are $27,000. Here’s how it breaks down:
$27,000-$2,000 (Deductible)=$25,000
$25,000 x 20% (Coinsurance)=$5,000
Sadie’s responsible for the $2,000 deductible Plus the Coinsurance ONLY up to her MOOP. So even though the deductible plus coinsurance is $7,000, Sadie only pays $6,000. This is where her responsibility ends. Also, medical costs that Sadie has for the remainder of the policy year are covered at 100%.

Ask Questions!
A knowledgeable Agent can help you weigh the available options and understand the plan you choose. Medical costs can be astronomical. Understanding your coverage can reduce your risk of those costs becoming your responsibility.

Request your Health Insurance quote today!