My health insurance policy includes a deductible and coinsurance. What does this mean?

The deductible on your plan must be satisfied before the insurance company will begin to pay any portion of the medical expenses. This is only applicable towards the benefits that are subject to the deductible and coinsurance. Many plans have copays for certain services where the deductible does not have to be satisfied, such as prescriptions or preventive care.

Coinsurance is the percentage of charges that are your responsibility after the deductible has been satisfied. Usually coinsurance ranges from 20% to 50%. The insurance company will pick up the remaining 80% to 50%.

What is a copay?

A copay is a small charge which you must pay at the time of your visit. The most common example is a doctor copay, which typically ranges from $10 to $40. Specialist copays are typically higher. There are also copays for hospitalizations for outpatient or inpatient. These are significantly higher and typically range from $250 to $1500.

What is a Carrier?

This is the insurance company or HMO offering the plan.

What is a Certificate of Credible Coverage

This is a document that is sent to you after your insurance policy has been terminated. It documents the duration of your coverage with that carrier and may be requested as proof of a Qualifying Event.  This certificate is sometimes called a Certificate of Prior Coverage or a HIPAA Certificate.

What is COBRA?

If you employer has more than 20 employees and, for some reason you lose your job, COBRA is Federal legislation that lets you continue on the Employer Group benefit plan(s) for up to 18 months.  You would be responsible for 102% of the total premium. 

What is HIPAA?

A Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. Full name is "The Health Insurance Portability and Accountability Act of 1996."

What are Usual, Customary & Reasonable Charges?

An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.

What is a Provider?

Provider is a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.

What are Exclusions?

These are services that are specifically not covered on a policy.

What are Limitations?

A limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.

 What is an SBC?

An SBC is a Summary of Benefit and Coverage.  It is a very general description of what is covered, what is not, and what your deductible, co-insurance and copays are.  

What is an Out-Of-Pocket Maximum?

A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses.  For plans that are Affordable Care Act (ACA) compliant, the Out-of-Pocket Maximum includes all deductible, co-insurance and copay amounts that you pay.