The More You Know—Start With The Lingo
February 2020 Issue
by Brelynn DuMortier
Since most us have new, or renewed, health insurance policies that started January 1, now is a good time to get up to speed on your health insurance terminology. The more you know and understand your insurance, the more use and value you will get out of it. So here we go:
Allowable charge: How much the insurance company has agreed to pay your provider for certain medical expenses, and how much your provider has agreed to accept. Can be based on usual, customary and reasonable amounts.
Balance Billing: The amount you are charged by the provider after your insurance has paid their portion. This can happen with out-of-network providers.
Certificate of coverage (COC): The document that goes into detail about what is and is not covered (exclusions) and in what circumstances.
Coinsurance: A percent of your medical bills that you must pay after your deductible is met, usually 20-50%. Your insurance company pays the rest
Copay: A flat amount you pay for certain office visits, treatments or services, for instance $20 to see your primary care provider.
Deductible: An amount you must pay before most insurance benefits kick in.
Diagnostic Services: Provider visits that may include testing to determine causes of symptoms. Tests are usually a separate charge from the office visit.
Emergency Room visits: Only for medical emergencies, such as trouble breathing, chest pain, stroke symptoms, sudden unusually bad headaches, loss of limb or digit, serious burns, broken bones, fainting, etc.
Exclusions: What the insurance company won’t cover. Always check your COC or SBC (summary of benefits coverage) for this information.
Explanation of Benefits (EOB): A document you receive after getting medical services, which shows the allowable amount, what the insurance company paid and your payment.
Formulary: A list of prescriptions the insurance company will cover, and which tier they fall under.
Health Savings Account (HSA): A bank account set up specifically for medical expenses, but can only be contributed to if you have an HSA-eligible insurance policy.
Network: Providers that have signed a contract with the insurance company agreeing to provide services for allowable amounts. You will generally pay less staying in network.
Out of pocket maximum: The most you would have to pay during a plan year for your medical expenses.
Preventative/Routine Services: Include shots, screening tests and checkups, often provided at no cost.
Provider: Health care professionals, clinics, hospitals or other medical facilities.
Summary of Benefits and Coverage (SBC): A brief outline of your benefits.
Urgent Care: Should be used if you can’t get in to see a primary care doctor for fevers, illnesses, sprains and strains, small cuts, flu symptoms, etc.
Usual, Customary, and Reasonable (UCR): Charges based on what other providers in the area are charging for the same or similar services. Can be used to determine allowable charges.
Tune in next time to my article about the benefits your policy may offer that you might be missing!