When searching for a health insurance plan or after one has already signed up, the plan terms, or descriptions of provisions and coverages can be hard to understand. When one is reviewing the terms they often confusingly say, “What does that mean?”
Help is here! Below is a list of common health insurance coverage terms to help everyone understand more about what their health insurance plan has to offer.
You may also be interested in the Health Insurance Reform Definitions
The deductible refers to the amount of money that the insured would need to pay before any benefits from the health insurance policy can be used. This is usually a yearly amount so when the policy starts again, usually after a year, the deductible would be in effect again. Some services, like doctor visits, may be available without meeting the deductible first. Usually there are separate individual deductible amounts and total family deductible amounts.
This is usually a percentage amount that is the insured's responsibility. A common co-insurance split is 80/20. This means that the insurance company will pay 80% of the procedure and the insured is required to pay the other 20%.
The co-payment is a fixed amount that the insured is required to pay at the time of service. It is usually required for basic doctor visits and when purchasing prescription medications.
This is the cost one would pay out of their own pocket. An out of pocket expense can refer to how much the co-payment, coinsurance, or deductible is. Also, when the term annual out-of-pocket maximum is used, that is referring to how much the insured would have to pay for the whole year out of their pocket, excluding premiums.
This is the most amount of money the health insurance policy will pay for the entire life. Pay attention to individual lifetime maximums and family lifetime maximums as they can be different.
The exclusions are the things that the insurance policy will not cover.
This is something someone had before obtaining the insurance policy. Some plans will cover pre-existing conditions while others may completely exclude them and, in addition, some health insurance plans will cover pre-existing conditions after a certain time period.
This is the time one would have to wait until certain health insurance coverages are available.
If the insured has available two or more sources that would cover payment for certain conditions, such being under a spouse's insurance plan along with their own, the insurance company would not pay double benefits. In this case the health insurance company would coordinate benefits to make sure each plan pays a portion of the service.
This is the amount of time one has to pay their health insurance premium after the original due date and before insurance coverage would be canceled.