Common Health Insurance Terms
The Benefit Companies, Inc.
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Here’s a list of common health insurance terms you might encounter:
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1. Premium Contribution: The amount you pay for your health insurance every month.
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2. Deductible: The amount you pay out-of-pocket for healthcare services before your insurance starts to pay.
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3. Copayment (Copay): A fixed amount you pay for a specific service (e.g., a doctor’s visit or prescription) at the time of service.
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4. Coinsurance: The percentage of costs you pay for covered services after you’ve met your deductible.
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5. Out-of-Pocket Maximum: The maximum amount you will pay for covered services in a plan year. After reaching this amount, the insurance pays 100% of covered services.
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6. Network: The group of doctors, hospitals, and other providers that are contracted with your health insurance plan to provide services at reduced rates.
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7. In-Network: Providers or facilities that are part of your health plan’s network and offer services at lower costs.
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8. Out-of-Network: Providers or facilities not contracted with your health plan, often resulting in higher costs for services.
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9. Preauthorization (Prior Authorization): A requirement to obtain approval from the insurance company before receiving certain services or medications to ensure coverage.
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10. Exclusions: Specific services or conditions that are not covered by the insurance policy.
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11. Waiting Period: A period of time you must wait after enrolling in a plan before you can access certain benefits.
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12. Essential Health Benefits: A set of health care services that must be covered by certain health insurance plans, including emergency services, maternity care, and mental health services.
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13. Lifetime Limit: A cap on the total amount of money an insurance company will pay for a covered individual’s healthcare over their lifetime (note: this is no longer permitted under the Affordable Care Act).
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14. Health Savings Account (HSA): A tax-advantaged savings account that can be used to pay for qualified medical expenses when you have a high-deductible health plan.
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15. Flexible Spending Account (FSA): An employer-established benefit that allows you to set aside pre-tax dollars for medical expenses.
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16. Claim: A request for payment or reimbursement for services provided, submitted to the insurance company.
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17. Benefits: The health care items or services covered under a health insurance plan.
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18. Preventive Care: Services that help prevent illness or detect health issues early, often covered at no cost to the insured.
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19. Condition Management: Programs offered by insurers to help members manage chronic conditions like diabetes or asthma.
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20. Marketplace Insurance: Health insurance plans that are available for purchase through the Health Insurance Marketplace established by the Affordable Care Act.
Understanding these terms can help you navigate the complexities of health insurance and make informed choices about your coverage.