My Smart Choice Health Insurance Guide©...Sample Health Insurance Plans – Summary of Benefits...

My Smart Choice Health Insurance Guide©

• Why should I want health insurance?

• Why is this important?

• What do I need and want?

• What are my choices?

• How much can I afford?

• How much will it cost?

http://extension.umd.edu/insure/consumer-resources

For use during the Spring 2013 project pilot testing

http://extension.umd.edu/insure/consumer-resources

Welcome to this guide.

Are you like most consumers?

You dread making decisions about health insurance.

You are not really sure if you should purchase health

insurance.

You don’t really understand the terms and provisions of

health insurance.

Maybe you’re not confident that you know enough to make

a smart choice.

Don’t worry. This guide was created just for you. We’ve shown you

the big questions to ask. We’ve provided a definition of important

words to know and sample plans to study.

We’ve included 3 worksheets to help you—

1. Identify your needs and wants

2. Compare health insurance plans

3. Prepare a spending plan

You will then be able to—

• Ask key questions • Make sense of answers • Use simple tools to choose • Pick out smart choices • Feel good about your choice

Created by Bonnie Braun, Extension Specialist on behalf of the

University of Maryland Extension Health Insurance Literacy Team. 4-3-13

My Health Insurance Needs Worksheet

SECTION 1: MY FAMILY’S DOCTORS VISITS

1) Do we have a general practitioner(s)? Yes No

2) Do we see any specialists? Examples: Allergist, OBGYN, eye doctor? Yes No

3) How many times did my family and I visit the doctor? Please fill in the chart below. Extra rows are provided for you in case you have a larger family.

You and your family’s annual wellness visit or physicals, done by your general practitioner, are now covered 100% with no out-of-pocket costs to you! Please keep that in mind when filling out this chart and do not include them in this calculation.

Person Doctors Seen Health Condition Treated

How Often Doctor(s) Seen

Me

Spouse/Partner

Child

Child

Below is a chart to figure out how often you and your family visits the doctor. Fill in the appropriate circle or if your number of visits isn’t shown, fill it in on the blank provided.

4) If we see specialists, how many different specialists do we see? +

5) About how many times did we each visit our general practitioner (outside of annual wellness visits/physical) in the past year?

+

6) About how many times did we visit specialists in the past year? +

7) In the past year, how many times did we go to urgent care? +

8) In the past year, how many times did we go to the emergency room?

+

9) I need to purchase insurance for how many people (You, spouse/partner, and child/children)?

+

Note: Use this section to help fill out the “My Health Insurance Policy Comparison Worksheet”


SECTION 2: MY FAMILY’S PRESCRIPTIONS

9) Do we take any prescription medicines (those prescribed by Yes No

a doctor and NOT the ones I buy over-the-counter at a store)?

I can use this chart to figure out what prescription medicines my family and I take and how much they cost.

I take: How often do I get refills? How much do I have to pay?

Example: Rhinocort Once a month $20

My spouse(partner) and/or Child(ren) take:

How often do they get refills? How much do I have to pay?

My total cost each year $

Note: Use this section to help figure out “My Health Insurance Policy Comparison Worksheet”

SECTION 3: CHANGES IN HEALTH CARE NEEDS

10) Is there anything coming up in the next 12-18 months that I Yes No

didn’t have to plan for last year? Note: Use this chart to think about new health situations we may have to plan for in the next

12-18 months.

New item I will have: What kind of insurance coverage will I need?

Does this mean I will need more or less coverage?

Example: I want to have a baby

Obstetrics and gynecology, hospital stay, prenatal medicine

More

Example: Child turning 27 Can’t be covered anymore on my insurance

Less

Early Retirement Can’t be covered by employer insurance

More

Overall, do I need more or less coverage for next year?


SECTION 4: COVERING HEALTH CARE COSTS

Please refer to “My Health Insurance Spending Plan Worksheet” to calculate your health care costs.

SECTION 5: PRIORITIZING MY HEALTH INSURANCE NEEDS

15) Based on my answers, I want to be sure to pay attention to these items when choosing an insurance plan (and there may be several of these that apply to my situation). To help identify the best plan for me and my family, I would rank from 1 (most important) to 6 (least important) the following :

The expected changes in health care needs that will happen to me and/or my family in the next

12-18 months.

The doctors my family and I see are included in the network of the health insurance plan.

The medicines that my family and I need are covered by the insurance.

The cost of insurance on a monthly (or annual) basis (this would be the premium).

The amount of out of pocket costs including emergencies, deductible, co-pay or co-insurance.

NOTES:

Created by

Virginia Brown, Extension Educator and Teresa McCoy, Assistant Director, University of Maryland Extension Maria Pippidis, Extension Educator, University of Delaware Extension,

Health Literacy Insurance Initiative Team

University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national

origin, marital status, genetic information, or political affiliation, or gender identity and expression.


University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national origin, marital status, genetic information or political affiliation, or gender identity and expression.

For use during the Spring 2013 project pilot testing. Turn over to next page

Sample Health Insurance Plans – Summary of Benefits

Sample 1 - EPO Sample 2 - POS Sample 3 - PPO

Sample Plan Overview In-network only In-network Out-of-network In-network Out-of-network Deductible: None - individual

None - Family

None - Individual None - Family

$125 Individual $250 Family

None - Individual None - Family

$125 Individual $250 Family

Out-of-Pocket maximum: None - individual None - Family

$500 - Individual $1,000 - Family

$1,500 - Individual $3,000 - Family

$500 - Individual $1,000 - Family

$1,500 - Individual $3,000 - Family

Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Unlimited National Network Yes No, Regional Yes Yes Yes Primary Care Physician Required Yes Yes No No No

Common and Preventive Services Primary Care Physician Office visit $15 copay $15 copay 70% of allowed benefit

after deductible

$15 copay 70% of allowed benefit after deductible

Specialist Office visit $30 copay $30 copay 70% of allowed benefit after deductible

$30 copay 70% of allowed benefit after deductible

Adult Physical Exams 100% of allowed benefit 100% of allowed benefit Not covered 100% of allowed benefit 70% of allowed benefit after deductible

Well Baby/Child Visits 100% of allowed benefit 100% of allowed benefit Not covered 100% of allowed benefit 70% of allowed benefit after deductible

Immunizations and Vaccines covered 100% of allowed benefit 100% of allowed benefit 70% of allowed benefit after deductible

100% of allowed benefit 70% of allowed benefit after deductible

Emergency Treatment Urgent Care $30 copay $30 copay 70% of allowed benefit

after deductible

$30 copay 70% of allowed benefit after deductible, plus

$30 copay Emergency Room Services $75 copay for ER facility

plus $75 copay for ER Physician services

$75 copay for ER facility plus $75 copay for ER

Physician services


Physician services


Physician services


Physician services

Ambulance Services – Emergency Transport 100% of allowed benefit 100% of allowed benefit 100% of allowed benefit 100% of allowed benefit 100% of allowed benefit Hospital Services

Inpatient care 100% of allowed benefit 90% of allowed benefit 70% of allowed benefit after deductible


Hospitalization 100% of allowed benefit 90% of allowed benefit 70% of allowed benefit after deductible


Outpatient Surgery 100% of allowed benefit 90% of allowed benefit 70% of allowed benefit after deductible


University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental disability, religion, ancestry, or national origin, marital status, genetic information or political affiliation, or gender identity and expression.

For use during the Spring 2013 project pilot testing. Turn over to next page

Sample 1 - EPO Sample 2 - POS Sample 3 - PPO Women’s Services In-network only In-network Out-of-network In-network Out-of-network

Well Woman Visits 100% of allowed benefit 100% of allowed benefit Not covered 100% of allowed benefit 70% of allowed benefit after deductible

Mammography (Preventive) 100% of allowed benefit 100% of allowed benefit 70% of allowed benefit after deductible


Maternity Benefits 90% of allowed benefit 90% of allowed benefit 70 % of allowed benefit after deductible


Other Services and Supplies Diagnostic Lab & X-Ray 100% of allowed benefit 90% of allowed benefit 90% of allowed benefit 90% of allowed benefit 70% of allowed benefit

after deductible

Durable Medical Equipment 100% of allowed benefit 90% of allowed benefit 70% of allowed benefit after deductible


Vision Services and Supplies Vision – Routine Exam – up to $45 (once

every plan year) Prescription lenses, frames, contact lenses -$200 every

12 months

Exam – up to $45 (once every plan year)

Prescription lenses coverage varies on type,

frames – up to $45, contacts - coverage

varies on type




varies on type




varies on type




varies on type

Source: State of Maryland Guide to Your Health Benefits, March 2013

Sample Health Insurance Plans – Summary of Benefits

Sample Monthly Health Insurance Premiums Sample Insurance Plan 1 person 2 people 3+ people

Sample 1 – EPO $375.00 $772.00 $ 947.00 Sample 2 - POS $390.00 $702.00 $ 975.00 Sample 3 – PPO $454.00 $817.00 $1134.00

Section 1: Health Insurance Plan/

Policy Costs

Option 1

Option 2

Option 3

Monthly premium amount

$_____ per month x 12 months= $_________

$_____ per month x 12 months= $__________

$_____ per month x 12 months= $_________

How much is

your copay or

coinsurance?

Use the

estimated

number of

visits from the

My Health

Insurance

Needs

Worksheet to

complete this

section.

General Office Visit:

$_______ per visit

X ____ visits =

$_______

$_______ per visit

X ____ visits =

$ _______

$_______ per visit

X ____ visits =

$_______

Hospital visits:

$_______ per visit

X ____ visits =

$_______

$_______ per visit

X ____ visits =

$_______

$_______ per visit

X ____ visits =

$_______

Specialists:

$_______ per visit

X ____ visits =

$_______

$_______ per visit

X ____ visits =

$_______

$_______ per visit

X ____ visits =

$_______

Dental:

$_______ per visit

X ____ visits =

$_______

$_______ per visit

X ____ visits =

$_______

$_______ per visit

X ____ visits =

$_______

Total estimated costs on copay/ coinsurance (Add up your estimate for each in this section).

$

$

$

My Health Insurance Comparison Worksheet

This worksheet will help you compare three health insurance options. Use the health insurance information provided to you by the insurance company to fill in the worksheet. Call the insurance company for more information if you can’t find the answers in their written papers. Use the information you calculated in Section 1 of the My Health Insurance Needs Worksheet to help estimate costs in Section 1 of this worksheet.

Important Words to Know

Health Plan - is a benefit

your employer, union or

other group sponsor

provides to you to pay for

your health care services.

Health Insurance Policy–

is for people who aren't

connected to job-based

coverage. Individual health

insurance policies are

regulated under state law.

Premium– the amount that

must be paid for your

insurance policy.

Copayment- the amount

you pay for a health service.

Coinsurance- your share of

costs of a covered service,

calculated as a %, of the

allowed amount for the

service. You pay this plus

any deductibles you owe.

Specialist -A specialist is a

doctor who focuses on a

specific area of medicine or

a group of patients to

diagnose, manage, prevent

or treat certain types of

symptoms and conditions.

2

Prescription drug costs

Is the cost of prescriptions covered?

Yes No If yes, $ per prescription x number of prescriptions filled



Does the plan/policy

cover your

prescriptions? (Find

out by checking

online or by calling

the company; ask about

the formulary)

Yes No

Yes No

Yes No

My total yearly

estimated costs on

prescriptions:

$

$

$

Vision

Total yearly estimated

costs for vision

$ premium $ per visit X visits

Out-of-Pocket Costs $ lenses $ frames





My estimated yearly

costs for vision

$

$

$

How much is the annual deductible?

Hospital Visit

$

$

$

Medical Care:

$

$

$

Prescriptions:

$

$

$

My estimated yearly

deductible costs $

$

$

What is the yearly out- of-pocket limit? Does it include the deductible?

$

Yes No

$

Yes No

$

Yes No

Total Estimated Yearly Health Care Costs

Add up all the green

boxes to calculate the

total out of pocket

costs for each option

$

$

$

Important Words to Know

Out-of-Pocket Costs -

Your expenses for medical

care that are not paid by

your insurance policy. Out-

of-pocket costs include

deductibles, coinsurance,

and copayments for

covered services plus all

costs for services that

aren't covered in your

health insurance policy.

Deductible- amount you

owe for covered health

services before your health

plan begins to pay.

Out of Pocket Limit—The

most you pay during a

policy period (usually a

year) before your health

insurance policy begins to

pay 100% of the allowed

amount. This limit never

includes your premium,

balance-billed charges or

health care your health

insurance policy doesn’t

cover. Some health

insurance policies don’t

count all of your

co-payments, deductibles,

co-insurance payments,

out-of-network payments or

other expenses toward this

limit.

3

Section 2: Accessing Medical Services Option 1 Option 2 Option 3

Do I have to take a health questionnaire to get the insurance? Yes No

Yes No

Yes No

Do ALL my providers (doctors, hospitals, specialists,

pharmacies, etc.) take this insurance? (Look on the company’s

website or call)

Yes No

Yes No

Yes No

Can I choose my medical service providers?

Yes No

Yes No

Yes No

Do I need referrals for specialists?

Yes No

Yes No

Yes No

Do I need pre-approval for medical procedures?

Yes No

Yes No

Yes No

Does this insurance accept the doctor’s billing or do I have to

pay upfront and get the insurance company to reimburse me?

Accept

Pay up front

Accept

Pay up front

Accept

Pay up front

If I have a pre-existing condition, will the health insurance

plan/policy cover me? (As of January 1, 2014 all health insurance will cover pre-existing conditions with few exceptions).

Yes No

Yes No

Yes No

What type of insurance plan/policy? POS— Point of Service—A plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. May require you to get a referral from your primary care doctor in order to see a specialist. PPO— Preferred Provider Organizations—A 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 the plan’s network but can use doctors, hospitals, and providers outside of the network for an additional cost. HMO— Health Maintenance Organization—A plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out -of-network care except in an emergency. May require you to live or work in its service area to be eligible for coverage. Often provide integrated care and focus on prevention and wellness. EPO— Exclusive Provider Services— A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).

POS

PPO

HMO

EPO

POS

PPO

HMO

EPO

POS

PPO

HMO

EPO


Important Words

to Know

Referral - is a special kind

of pre-approval that health

plan members must

obtain from their primary

care physician before

seeing a specialist.

Pre-approval- decision by

your health insurer that health care service,

treatment plan,

prescription drug or

durable medical

equipment is medically

necessary. Sometimes

called pre-authorization,

prior approval or

pre-certification.

Pre-existing condition-

A condition, disability or

illness (either physical or mental) that you have

before you're enrolled in a

health insurance plan/ policy.

4

Section 3: Coverage

Option 1

Option 2

Option 3

This plan/policy covers these services (Covered essential and other services):

Note: Include coverage for any family

members. Check for services you and your

family use now or expect to use, including

prescriptions, maternity, mental health, etc.

This plan/policy does NOT cover these services

(Excluded services):

Note: Include coverage for any family

members. Check for services you and your

family use now or expect to use, including

prescriptions, maternity, mental health, etc.

What would be the costs associated with

these services not covered by Insurance?

$

$

$

Are any treatments or care specifically excluded?

What events are considered “approved emergency room vi sit ” events?

Are maternity benefits covered?

Is there a waiting period on maternity

benefits and how long is it?

If so, how long:

If so, how long:

If so, how long:

Are there any special limits or exclusions on

maternity benefits?

Are there pre-approval requirements for

hospital admission?

Will you qualify for coverage under

COBRA if your job ends?

Important Words to

Know

Covered Essential

Services –essential

benefits include:

emergency services,

hospitalizations, laboratory

services, maternity care,

mental health and

substance abuse

treatment, outpatient or

ambulatory care, pediatric

care, prescription drugs,

preventive care,

rehabilitative and

habilitative services, vision

and dental care for

children.

Approved Emergency

Room visits—types of

visits that will be covered

by insurance. Non-

emergency use of

emergency room will

typically not be covered by

insurance.

COBRA -A Federal law

that may allow you to

temporarily keep health coverage after your

employment ends, if you

lose coverage as a

dependent of the covered

employee, or another

qualifying event. If you

elect COBRA coverage,

you pay 100% of the

premiums, including the

share the employer paid,

plus a small

administrative fee.

5

Section 4: Other Considerations

Option 1

Option 2

Option 3

If I travel, does this plan/policy cover care

outside my local area?

Yes No

Yes No

Yes No

Does this plan/policy have coordination of benefits with other health insurance?

Yes No

Yes No

Yes No

Is this insurance plan/policy authorized to do

business in my state? (To find out, call your

state’s Insurance Commissioner’s Office).

Yes No

Yes No

Yes No

Does the company have a high number of

consumer complaints? (To find out, call your

state’s Insurance Commissioner’s Office).

Yes No

Yes No

Yes No


Important Words

to Know

Coordination of

Benefits -

coordination of

medical services

between medical

providers OR

coordination of

insurance coverage

between insurers.

Adapted by

Maria Pippidis, Extension Educator, University of Delaware Extension,

Virginia Brown, Lynn Little and Mia Russell, Extension Educators, University of Maryland Extension

for the Extension Health Insurance Literacy Initiative

from the Washington State Office of the Insurance Commissioner and the University of Missouri Making Money Count Curriculum, Chapter 7.

University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation,

physical or mental disability, religion, ancestry, or national origin, marital status, genetic information, or political affiliation, or gender identity and expression.

For use during the Spring 2013 project pilot testing.

Utilities

Electric Heating oil or gas Trash/garbage Water and Sewer Sewer Telephone Cable TV Internet Cell phone Other Total

Food

Groceries Food away from home School lunches Other Total

Transportation

Car/truck payment Car Insurance Maintenance/repairs Gasoline, oil, etc. Other Total

Personal

Clothing Personal Care Tobacco/alcohol Total

Family Care

Child Care or other dependent care

Personal Allowances

Total

Health and Medical

Insurance premium (not deducted from paycheck)

Insurance copay(s)/ co-insurance costs

Prescriptions Over-the-counter medications

Vision Dental Health Savings Acct Total

Educational Expenses

Tuition Sports and organizational fees

School supplies Total

Pet Care

Pet food Pet supplies Veterinary services Pet care (grooming, boarding, etc.)

Total Entertainment

Movies, books, etc Vacation Hobbies, etc. Total

Gifts & Charitable Contributions

Gifts for others Charitable contributions

Total

Credit Payments

Credit Card # 1 Credit Card # 2 Credit Card # 3 Personal loan payments

Total Periodic Expenses

Expenses that come up once or twice a year. Fill in the estimated costs under the month they are due. Add your total and divide by 12 to determine the monthly portion.

Jan Feb Mar Apr May June July August September October November December Subtotal Subtotal ÷12 = Monthly portion of periodic expenses

Deductions taken from your paycheck:

Federal taxes State taxes FICA Social Security Medicare Insurance Premiums:

Life insurance Health Insurance Disability Insurance

Flexible Spending Acct

Retirement Savings Other Savings (payroll deduction)

Other deductions Total deductions

Housing

Rent or Mortgage Insurance (Homeowner/Renters)

Property taxes Maintenance/repairs

Total

Monthly Income (Gross pay before

deductions)

Wages/salary #1 Wages/salary #2 Other sources:

Total Income

Expenses:

My/Our Monthly Spending Plan Worksheet

SUMMARY

Total Monthly Income

Total Monthly Expenses

University of Maryland Extension programs are open to all citizens and will not discriminate against anyone because of race, age, sex, color, sexual orientation, physical or mental

disability, religion, ancestry, or national origin, marital status, genetic information, or political affiliation, or gender identity or expression.


OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146 Glossary of Health Coverage and Medical Terms Page 1 of 4

Important Words I Need to Know

Glossary of Health Coverage and Medical Terms • This glossary has many commonly used terms, but isn’t a full list. These terms and definitions are intended to be

educational and may be different from the terms and definitions in your plan. Some also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See Summary of Benefits & Coverage for information on how to get a copy of your policy or plan document.)

• Bold blue text indicates a term defined in this Glossary.

• See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation.

Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)

Appeal A request for your health insurer or plan to review a decision or a grievance again.

Balance Billing

Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example,

to pay. For example, if your deductible is $1000,

Jane pays 100%

Her plan pays 0%

if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30.

your plan won’t pay anything until you’ve met

(See page 4 for a detailed example.)

A preferred provider may not balance bill you for covered services.

Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed

your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

amount for the service. You pay co-insurance

Jane pays

20%

Her plan pays

80% Emergency Medical Condition plus any deductibles you owe. For example,

(See page 4 for a detailed example.) An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid

if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non- emergency caesarean section aren’t complications of pregnancy.

severe harm.

Emergency Medical Transportation Ambulance services for an emergency medical condition.

Emergency Room Care Emergency services you get in an emergency room.

Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

Glossary of Health Coverage and Medical Terms Page 2 of 4

Excluded Services Health care services that your health insurance or plan doesn’t pay for or cover.

Grievance A complaint that you communicate to your health insurer or plan.

Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of

inpatient and/or outpatient settings.

Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.

Home Health Care Health care services a person receives at home.

Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital Outpatient Care Care in a hospital that usually doesn’t require an overnight stay.

In-network Co-insurance

Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

Non-Preferred Provider A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out- of-network co-insurance usually costs you more than in- network co-insurance. Out-of-network Co-payment A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network co- payments usually are more than in-network co-payments.

Out-of-Pocket Limit The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed

The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who

amount. This limit never includes your premium,

Jane pays

0% Her plan pays

100%

contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network

balance-billed charges or health care your health

(See page 4 for a detailed example.)

co-insurance.

In-network Co-payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.

insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

Physician Services Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.


Plan A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

Premium The amount that must be paid for your health insurance

or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications.

Prescription Drugs Drugs and medications that by law require a prescription.

Primary Care Physician A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Primary Care Provider A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Provider A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.

Rehabilitation Services Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient

and/or outpatient settings.

Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

How You and Your Insurer Share Costs - Example Jane’s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000

January 1st

Beginning of Coverage

Period

December 31st

End of Coverage Period

Jane pays

100%

Her plan pays

0%

more

costs

Jane pays

20%

Her plan pays

80%

more

costs

Jane pays

0%

Her plan pays

100%

Jane hasn’t reached her $1,500 deductible yet Her plan doesn’t pay any of the costs.

Office visit costs: $125 Jane pays: $125 Her plan pays: $0

Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit.

Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60

Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year.

Office visit costs: $200 Jane pays: $0 Her plan pays: $200


My Smart Choice Health Insurance Guide©...Sample Health Insurance Plans – Summary of Benefits...

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