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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

Fall is a time for back to school, state fairs, “leaf-peepers,” and thinking about your healthcare insurance. Open Enrollment season, as we call it in the business, begins November 1 and lasts through January 15, 2022. This season brings some positive changes in health insurance including changes in Health Options’ plans.

First, all health insurance carriers in the individual/family marketplace will offer Clear Choice plans to bring more transparency to the buying process. These plans are designed to make it easier for Maine people to compare options across health insurance carriers. Clear Choice plans have a standard cost-sharing design, meaning they have the same deductible, co-pays, and co-insurance for medical services across all health insurance carriers in the state. All Health Options’ Clear Choice plans are designated with “CC” in the plan name.  It is important to note there may be some differences between carriers in clear choice plans, so you will want to look beyond the cost-sharing. For example, Health Options offers a chronic illness support plan to reduce the cost of care for Members with asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, and hypertension in many clear choice plans, and other carriers do not have this exact benefit. 

Also, for 2022, Health Options is pleased to add a tiered provider network to some of our individual/family HMO plans. In our tiered plans, primary care providers, imaging, labs, and out-patient hospital services are categorized by a preferred or standard tier.  The preferred tier offers high quality, lower cost-share providers and service options. Plan Members are easily directed to preferred tier providers and locations when completing a provider search. Tiered plan Members can continue receiving services from a standard tier provider with a standard co-pay. 

In another change to our provider network selections, we offer several plans that include national in-network coverage through First Health®. These plans are ideal for individuals and families who spend time outside the New England region and need reliable coverage both at home and on the road. Other plan enhancements include $0 cost for urgent care telehealth on non-HSA plans through our partnership with Amwell®. Health Options will also be offering Maine’s only Platinum health plan in the individual/family marketplace, which has the lowest deductible and cost-share across plans and offers co-pays with no deductible for in-network primary care, specialists, behavioral health visits, and urgent care facilities.

Finally, there are some legislative changes affecting health insurance in Maine. If you’ve used Healthcare.gov to learn about tax credits and other cost reductions, you will now be using CoverME.gov, Maine’s new online Health Insurance Marketplace. CoverME.gov is operated by the Maine Department of Health and Human Services. With the American Rescue Plan enacted earlier this year by the Biden Administration, more Mainers than ever are now eligible for advance premium tax credits (APTC) to help pay for coverage. Be sure to visit our storefront (healthoptions.org) to check your eligibility for tax credits and go to CoverME.gov after November 1, 2021, to January 15, 2022, to apply for the APTC and/or for cost-sharing reduction credits.

While these changes are all good news, we know how hard it can be to navigate health insurance decisions. As always, we are here for you. Our Member Services team can address any questions you have regarding your 2022 healthcare coverage. If you need help selecting a plan, go to healthoptions.org or call Member Services at (855) 624-6463, Monday through Friday, 8:00 a.m. to 6:00 p.m.  You can also reach out to your trusted broker.