Navigating the ins and outs of your medical insurance plan can be confusing and frustrating. It’s not uncommon for our office to receive calls from patients who seem genuinely surprised that their insurance did not cover 100% of their bill. No one enjoys unexpected financial responsibilities and yet, statistics show that over 45% of Americans do not understand their current insurance coverage. Taking the time to do a little research at the beginning of the year (when plans often change) and understanding the meanings of a few key insurance terms can help eliminate frustration and minimize your financial impact.
What does PPO mean? (Preferred Provider Organization)
PPO stands for Preferred Provider Organization and is a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to your plan’s network. You may be able to use doctors, hospitals, and providers outside of your network or PPO for an additional cost.
What does Non-Participating Provider mean?
A non-participating provider means the doctor, hospital or clinic does not have a contract with your health insurance plan. A non-participating provider does not mean you can’t see or use their services, but you will pay more out of pocket expenses if you choose this option.
What does copay mean?
A copay is a fixed amount you must pay for any covered health care service. Copays are typically collected when you arrive for your appointment. Not all plans require copays but providers are contractually obligated to collect it if you do. The amount you are responsible for is usually printed on your card. The copay amount may vary depending on the type of visit as well (PCP, Specialty, ER).
What does deductible mean?
A deductible is the amount you owe for your health care services before your insurance plan will begin to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your deductible for covered services that are subject to that deductible. The deductible does not apply to all services. This can be very confusing. Some plans cover wellness exams or preventative care 100% before you meet your deductible, others only cover lab or x-rays, etc.
What is a covered service?
A covered service is one that the policy holder is entitled to under the terms of the contract. Covered services can also be confusing because even if the patient is entitled, the service may not be paid if you have not met your deductible yet (see above).
Who is the primary subscriber?
The primary subscriber is the individual under whom the plan is held (often the employee of the company sponsoring the plan).
Who is considered a dependent?
A dependent is any additional family member covered under the primary subscriber (see above).
What does Pre-Authorization mean?
A preauthorization is a decision or approval given by your health insurer that a specific service, treatment plan, prescription drug or durable medical equipment is medically necessary. Preauthorization can sometimes be referred to as prior authorization, prior approval or precertification. Your health insurance may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization is not a promise your health insurance plan will cover the cost.
What is an EOB (Explanation of Benefits)?
An EOB is the health insurance company’s written explanation of how a medical claim was processed and paid on their end. The EOB contains detailed information about the insurance company paid and what portion of the costs you are responsible for. A copy of the EOB is also sent to your medical provider.
Do the research on your insurance and insurance terms before scheduling appointments, especially if you are going to an office for the first time. If you are unsure of your coverage, call the phone number on your insurance card and ask questions. Another great resource to utilize is the HR department of the company you are covered under, there is usually a designated benefits specialist that should know the basic details of your plan. Some of the larger insurance companies offer online customer service access as well as regular newsletters to keep you informed of any changes.
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