Health Ins Basics:
You should know these terms to understand the details of the potential coverage.
Benefits: the services that your health care provider agrees to cover. Examples of common benefits include preventive care, visits to the doctor when sick, prescriptions and medical equipment. This does not mean that the insurer covers all costs; It may be partially covered.
Coinsurance: Unlike co-payments, which require you to pay an agreed fixed rate, co-insurance requires that you share a percentage of your medical costs with your insurer. The common percentage rates are 80/20 or 70/30, which means that your insurance company will pay 80 or 70 percent of the services, and you will pay the rest. Coinsurance payments are sometimes associated with out-of-network services, many of which will end up being specialized and expensive treatments.
Deductible: This is the amount of money you must pay before your insurance provides coverage. For example, if your deductible is $ 1500, you must pay that amount in health costs before the insurer contributes. However, not all plans have a deductible, and not all services are subject to the deductible. For example, requesting preventive care or a sick visit usually requires a copayment or coinsurance payment, but does not count toward your deductible amount. The explanation of your benefits will list exactly which health services are subject to the deductible.
Out-of-pocket limit: Even after reaching your deductible, you can still be responsible for copayments and coinsurance up to your out-of-pocket limit. This means the absolute total that you will have to pay in one year. After this point, the insurance covers all costs.
Health Maintenance Organization (HMO) Plan: A plan that provides coverage and health care services, HMOs will often require you to see exclusively providers and hospitals included in the health network. You will get comprehensive benefits within the network, but less flexibility if you leave the network. And when you leave the network, you probably need a referral from a doctor within the network. Kaiser Permanente, for example, is one of the largest HMOs in the country.
Participating Provider Organization (PPO) Plan: An insurance plan that allows you to choose your doctor from among those who are “participating” in that insurer’s coverage. This is more flexible than an HMO plan. You will be covered for in-network care and may be partially covered for out-of-network care.
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