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Health Insurance Lingo, Translated

Oct 05, 2021
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Health insurance talk can feel like another language. And even for those of us who are fluent in it, there’s still room for confusion! Read on for a crash course in translating health insurance lingo into language you can better understand.

First, there are the words associated with healthcare insurance costs.

  • Premium: Just like car insurance or cable bills, your premium is what you pay upfront to have health insurance coverage. You and/or your employer usually pay a premium monthly, quarterly, or yearly.
  • Deductible: This is the amount you must spend for your own covered healthcare services before your health insurance plan begins to pay. Keep in mind that there are low or no-cost provider visits, services, and medications (like preventive care) available before you pay the deductible. But for other care, with a $2,000 deductible – for example – you pay the first $2,000 before the insurance company pays. If your plan has out-of-network coverage, there may be a separate deductible for out-of-network coverage.
  • Co-payments: These are fixed amounts you pay at the time of a covered healthcare service, like a lab test, a provider visit, a prescription, or an urgent care visit. For example, if your health insurance plan's allowable cost for a doctor's office visit is $100, your cost-sharing co-payment might be $20. You may have different co-pays for in-network and out-of-network provider visits/services.
  • Co-insurance: After you hit your deductible, you and your insurance company will share any remaining covered healthcare costs. This is called co-insurance and if your co-insurance is 60% for example, your insurance company will pay 60% of the cost. You will pay the remaining 40% (up to the maximum out-of-pocket amount – see below). Percentages may differ for out-of-network coverage if it is available in your plan.
  • Maximum out-of-pocket (MOOP): This is the maximum amount that you pay in any given plan year for ALL covered services before your benefits will pay 100% of remaining covered expenses in that year. Once you hit your MOOP, the insurance company will pay 100% of any additional covered services. The total money you spend on your deductible, co-pays and co-insurance are added together to get to the MOOP. You may have a separate MOOP for in-network and out-of-network coverage.

Here are a few more words and acronyms that will help you understand and maximize your benefits while keeping costs in check:

  • In-network: In-network refers to the group of care providers who have negotiated (lower) fees with your health insurance provider. Using an in-network care provider will help you pay less for your healthcare services.
  • Out-of-network: These providers are not currently contracted with your insurance company, so using them could mean higher costs. HMO plans typically provide no coverage for out-of-network providers, except for emergency care. While PPO plans do cover out-of-network care, the cost-sharing is usually higher than with in-network options, with some exceptions, such as emergency care. If you don’t have out-of-network coverage, you will be responsible for the full cost of an out-of-network visit/service unless it qualifies as emergency service.
  • Primary Care Provider (PCP): This is the doctor you see most often for primary care and for coordinating any specialty care. PCPs can be any in-network healthcare provider in internal medicine, family practice, general practice, pediatrics, or obstetrics and gynecology, a certified nurse practitioner, physician assistant, or certified, licensed nurse-midwife.
  • HMO: Stands for “Health Maintenance Organization.” The defining characteristic of an HMO is that you are required to choose an in-network primary care provider (PCP) to coordinate your care. Your PCP provides referrals to access specialty providers and services within the plan, which helps keep costs in check. HMOs do not cover out-of-network services, except for emergency care.
  • PPO: Stands for “Preferred Provider Organization.” PPOs may also require that you select an in-network PCP, but they offer both in-network and out-of-network benefits. Out-of-network cost-sharing is generally higher than in-network, but you have access to a larger number of providers.

This is a lot of words and letters! Still have questions? Call us at (855) 624-6463. Our Maine-based Member Services team is happy to help!

SEE ALSO

The year ahead comes with a few changes to Health Options’ health insurance plans – and it’s all good news. One change we are excited to announce is a new tiered provider network option available in select individual/family Health Maintenance Organization (HMO) plans. While tiered plans may be new to Health Options, they are not new to health insurance. In fact, they are a proven way to save money on medical expenses. Read on to learn what tiering means to insurance plans and what it means to you as a health insurance consumer.

Tiered provider networks are a way to better manage the costs of healthcare services. They also provide health insurance consumers a better way to consider the cost of care when choosing their care options. Plans featuring tiered provider networks generally combine quality and cost in developing a preferred tier. Providers with high-quality outcomes and lower contracted prices are typically placed in the most preferred tier rankings.

As a consumer, you may wonder how Health Options decides which providers are considered part of our preferred tier. It is important to note, that all providers meet our quality standards, which is why they are part of the Health Options network. For tiered providers, we review claims history to analyze the quality of provider outcomes combined with their contracted cost and efficiency. Providers and facilities that meet or exceed our standards for quality, cost, and efficiency are “preferred,” and others are “standard.” 

To take advantage of tiered providers, you will need to select an individual/family plan with a tiered network option, which is available in both bronze and silver metal level plans for 2022. It’s important to note, that on a tiered plan, you always have the option to visit standard providers with a standard co-pay. 

As we enter the Open Enrollment season for 2022, we are proud to offer the highest quality healthcare at the best possible value with all our plans, and our new tiered network offers additional savings. If you have questions about tiered network plans and want help finding the health insurance plan that best suits your needs, contact our Member Services team at (855) 624-6463.