chevron_leftBlog
Home Blog HealthInsuranceLingoTranslated

Health Insurance Lingo, Translated

Oct 13, 2023
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.
  • Copayments: 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 copayment might be $20. You may have different copays for in-network and out-of-network provider visits/services.
  • Coinsurance: You and your insurance company share covered healthcare costs. This is called coinsurance and if your coinsurance is 40% for example, your insurance company will pay 60% of the cost. You will pay 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, copays and coinsurance 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 contracted 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. Even with out-of-network coverage, you may be responsible for provider service fees above the covered rate. This is called balanced billing.
  • 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 and rarely require a referral to see a specialist, although specialists may require a referral. 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? For quick tips on what to look for, how to get help with, or how to use a health plan, follow @communityhealthoptions on TikTok. Or call us at (855) 624-6463. Our Maine-based Member Services team is happy to help!

SEE ALSO

Community Health Options will soon expand its virtual health services and provide Members access to virtual primary care providers, giving them consistent care when they need it anytime, anywhere. The new service can help make it easier for Members struggling to find a nearby provider accepting new patients, whether they need preventive and routine care or help managing more complex issues.