chevron_leftBlog
Home Blog HealthInsuranceLingoTranslated

Health Insurance Lingo, Translated

Oct 05, 2021
reading takes 3 min

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

What to Know About the American Rescue Plan Act

You may be eligible for financial help with health insurance costs.

There is good news about your health insurance coverage.  The American Rescue Plan Act recently increased the Marketplace tax credit dollars at every income level. With this new legislation, you could qualify for premium tax credits that you can use to lower your monthly insurance payment. This legislation, combined with the Open Enrollment extension through August 15, 2021, means more time for individuals and families to enroll and get financial help with Marketplace coverage.

How can you determine your eligibility?

We encourage you to visit healthoptions.org to obtain a summary of your Marketplace eligibility. Click on “Find a plan;” select ”Shop as an individual or family,” and answer a few basic questions to receive an estimate of your eligibility.

I am eligible for tax credits. What should I do?

If you are eligible for an additional or new tax credit, you must contact the Marketplace by calling (800) 318-2596 or visiting healthcare.gov.

Can I change my  Health Options’ plan?

Yes, now through August 15, you can switch to another Health Options’ plan based on your health insurance needs, your budget, and this additional financial help.

Will my 2021 expenditures from my current Health Options’ plan transfer to a new Health Options’ plan?

Yes, any 2021 expenditures towards your deductible or out-of-pocket maximum will carry over to any new Health Options’ plan you choose.*

When will my monthly insurance payments be updated?

Changes to your invoice will become effective the first day of the month after you contact the Marketplace. 

Although healthcare.gov determines eligibility for a Marketplace plan and premium tax credits, we are here to help answer any questions you may have about our plans. Please contact us at (855) 624-6463, Monday through Friday, 8 a.m. to 6 p.m.

*Please note: Your 2021 payments applied to deductible and out-of-pocket maximum will carry over to your new Health Options’ plan as long as there is no interruption in coverage and you are not moving from a Health Options’ group plan to an individual plan.