10 Health Insurance Terms You Need to Know
By: CIGC Staff
Health insurance, and all the intricacies that go along with it, can be difficult to make sense of — especially when you’re dealing with a complex GYN condition and planning your health care. Open enrollment season is right around the corner, so now is the time to start looking at your health insurance benefits to ensure they’re giving you the coverage you need. With that in mind, here are 10 terms and definitions you need to know to get the most out of your health insurance plan.
On This Page:
- What Is a Premium?
- What Is a Copayment?
- What Is Coinsurance?
- What Is a Deductible?
- What Is My Out-of-Pocket Maximum?
- What Is an HMO Plan?
- What Is a PPO Plan?
- What Is a POS Plan?
- What Does In Network or Out of Network Mean?
- What Is Open Enrollment?
Your health insurance premium is the amount of money you (or your employer) pay each month to keep your policy active. This is usually a fixed amount paid each month regardless of whether you use your health care benefits. The amount you pay for your premium is dependent on factors such as your age, location, family size and the level of your plan. Plans with higher coverage amounts will typically come with higher monthly premiums.
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Your plan’s deductible is what you are responsible for paying before your insurance provider begins to pay for covered services. The deductible resets annually, so if yours is $1,000 your insurance won’t start paying its share until you’ve spent that amount on health care services in any given year. Your policy details which services are subject to your deductible. Preventative care like your annual physical is usually not subject to your deductible and may only require a copayment. Plans with higher deductibles typically have lower premiums, though you may be on the hook for more money out of pocket if you find yourself needing extensive medical care during the year.
A copayment (or copay) is a fixed amount of money you pay for a health service that is covered under your insurance policy. Copayments will vary for different types of services, such as prescriptions, doctor visits and lab tests. Under some plans and for some services, your copayment is subject to your deductible, meaning you’ll only pay your fixed copayment after you’ve reached your deductible amount for the year. For example, if your visit to the doctor is billed as $100 and your typical copay is $20:
- Subject to deductible: You’ll pay the full $100 if you haven’t yet met your deductible.
- Not subject to deductible: You’ll pay your $20 copayment while your insurance pays the remainder.
Even after you’ve met your deductible, that doesn’t always mean your responsibility for medical costs is over for the year. Many plans have coinsurance policies that kick in after the deductible has been paid. If your coinsurance is 20%, that’s the percentage you will pay for any medical service for the rest of that year (or until you reach your out-of-pocket maximum). For a $100 doctor’s visit, you would be responsible for $20 while your insurance provider pays the remaining $80.
Your out-of-pocket maximum is the cap on what you’ll have to pay for covered health expenses in a year. Your deductible, coinsurance and any copayments all go into your out-of-pocket maximum, which resets each year. After you’ve reached your maximum, your health insurance provider will pay 100% of any medical costs covered under your plan for the rest of that year. Your monthly premium costs do not count toward your out-of-pocket maximum.
Your deductible, coinsurance and any copayments all go into your out-of-pocket maximum, which resets each year.
Each health insurance company has a network of preferred health care providers. An in-network provider has contractually agreed to accept discounted rates for their services under a particular insurance company. Out-of-network health care providers have not agreed to these rates. Visiting a doctor who is in network with your insurance company will usually translate to lower costs for that doctor’s services.
A health maintenance organization (HMO) plan typically has lower monthly premiums, deductibles and copayments, but also gives you less flexibility on which health care providers you can see. Under some plans, you may be required to designate a primary care physician and you may need a referral before you see a specialist. HMO plans have no out-of-network coverage, so if you visit an out-of-network doctor you would be responsible for the entirety of the cost.
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Preferred provider organization (PPO) plans have a network of preferred providers, but they’ll also provide a lower level of coverage for out-of-network doctors and facilities. Most PPO plans do not require a primary care doctor referral to see a specialist, giving you extra flexibility for care — often at a higher premium cost.
With a point of service (POS) plan, you are required to get a referral from your primary care physician before seeing a specialist. POS plans have greater flexibility for seeing both in-network and out-of-network physicians than HMO plans, but you’ll likely pay higher expenses if you choose to go out of network.
Open enrollment usually comes around at the end of the year (though some employer-based plans follow different fiscal year calendars). This is the time when you can make changes to your health insurance plan before everything resets in the new year. At other points in the year, qualifying life events like job changes, marriages or births and adoptions will begin a special enrollment period that allows you to make changes outside of the regular enrollment period.
With the end of a plan year comes your “use it or lose it” benefits, which will not roll over into the next year. Your monthly premium pays for these benefits — don’t forget to use them to maximize your savings! At The Center for Innovative GYN Care, our patient advocacy team can help you navigate those remaining benefits and walk you through any changes you’d like to make ahead of your next open enrollment period.
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CIGC is dedicated to providing information and materials for women to help navigate the complicated health care system. The CIGC founders, minimally invasive GYN surgical specialists Paul MacKoul, MD, and Natalya Danilyants, MD, developed their advanced GYN surgical techniques using only two small incisions with patients’ well-being in mind.
Their personalized approach to care helps patients gain a better understanding of their condition and the recommended treatment so they can have confidence from the very start. Our surgeons have performed more than 25,000 GYN procedures and are constantly finding better ways to improve outcomes for patients.
Our patient advocacy team helps patients get the most out of their health insurance. They will contact your health insurance provider to confirm your plan has participating benefits, calculate your out-of-pocket costs and file any necessary paperwork with your insurance provider on your behalf.
At CIGC, we take the guesswork out of the process so you can focus on what’s most important: finding relief and getting back to your life.