Insurance Glossary

Let's face it: health insurance is confusing and a great source of frustration. Learning how your coverage works takes time, but pays off in confidence regarding your personal understanding of what can be a very convoluted system. Here are a few terms and concepts to get you started. 

Usually, once you reach your deductible, you are responsible for a smaller percentage of healthcare costs. These percentage splits vary, but a popular one is 80/20, with the insurance company paying 80% and you the other 20%. Coinsurance splits can also vary between different kinds of visits and procedures. 

Some plans have a copay, which is an amount you pay before leaving our office. Say you have a copay of $20 and bring two of your children in for a sick visit. Before leaving, you will pay $40 at checkout. If you brought only one child, you would pay $20. 

A deductible is an amount that you must pay before insurance coverage either begins or increases to a higher rate. These amounts vary considerably from plan to plan. 

Explanation of Benefits (EOB) can be one of the most useful tools to understanding your insurance coverage. You should receive an EOB in digital or hard copy each month from your insurance company. It will explain charges for doctors and procedures, how much insurance paid, and what you are responsible for (if anything). If a certain visit or procedure was not covered, the EOB will provide a reason why. In such cases, call your insurance provider to learn more. 

You may be offered a Health Savings Account (HSA) that you can use to put toward copays and other healthcare costs (specifics may apply, according to your HSA provider). HSAs are usually a set amount each year to use at your own discretion. You may receive a debit card with these funds, or your insurance company may work with your HSA provider directly. 

In-network providers are those who carry your insurance plan; it is typical for a network to expand regionally and statewide. Most insurance companies provide online portals where you can look up in-network providers in your area. Out of network providers do not carry your insurance plan; therefore, your coverage will not contribute to those healthcare costs. A good rule of thumb: out of network = out of pocket.  

If your statement has a line that says "Needs Other Info" and your insurance didn't pay anything on the visit, they need you to call them or log into your app to answer questions for them regarding any secondary insurance. Typically, they will not pay on any claims going forward until they hear from you. Once they receive the information they need, they will begin processing claims again. You will typically need to contact them at least once per year to update this information.

Once you have met your deductible there is a higher amount you can reach called your Out of Pocket Maximum. You will pay coinsurance until you reach your Out of Pocket Maximum. Once you reach this number, your healthcare should be covered by your insurance company 100%. 

Some insurance plans cover preventive/well patient visits completely. In pediatrics, this applies to check-ups before 24 months, yearly physicals 3 years and older, and generally includes immunizations. Read your coverage paperwork or call your insurance provider to learn if your plan features this benefit.