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UNDERSTANDING… Health Insurance Terminology, Oh, My!

With the multitude of health insurance policies available, it’s important to be a smart consumer in today’s ever-changing world of insurance. Knowing your insurance coverage and the terminology used by the industry is essential!

In years’ past we had healthcare coverage that seemed fairly simple, reasonable and covered mostly everything – that is not true of today’s insurances. Today’s policies often dictate the providers you can see, the facilities you can go to and the prescriptions you take; at the same time, impacting your wallet with higher deductibles, co-pays and out-of-pocket expenses.

To combat the growing frustration of healthcare insurance, you must first understand the terminology used in order for your coverage to be used effectively. The list below defines many common healthcare terms that apply to most policies.

Group Health Insurance: Insurance typically purchased through your employer.

Individual Insurance: Insurance purchased by an individual or family that is not tied to an employer.

Premium: The amount of money charged by the insurance company for coverage. Rates can be paid monthly or yearly.

Deductible: The amount of money owed per year before the insurance company starts to pay for health care services. Deductibles may not apply to all services, such as preventative care. Once the deductible is met, the insurance company will then start to pay a portion or the whole cost. Deductible amounts range per policy.

Copayment: An upfront fee paid to the healthcare provider at the time of healthcare services. This fee may or may not apply to the deductible. Copays vary depending on the policy and the services (primary provider vs. specialist or ER). Providers are expected by the insurance carrier to collect copays. Not all plans have copays.

Coinsurance:  A percentage paid once the deductible has been met. For instance, if the coinsurance is an 80/20 plan, the insurance company pays 80 percent of the billed services while you pay the remaining 20 percent. Percentages vary per plan.

Out-of-Pocket Maximum (OOPM): The most you will pay for your health care during a one year period, excluding your premium cost. Once the OOPM is met, the plan will begin paying at 100 percent. OOPM vary per plan.

In-Network Providers or PPO (Preferred Provider Organization) Plan: A list of doctors and providers participating in your insurance company’s network. Lower costs apply with in-network or PPO providers. Out-of-network providers can be utilized; however, beware the visit will not be cost efficient and will cost you more as the consumer.

Out-of-Network Providers: These are doctors and providers that are not participating in your insurance company’s network. Cost associated with out-of-network providers are higher and sometimes not covered by your plan.

HMO (Health Maintenance Organization): HMO plans offer health care services with specific HMO providers. Typically you select a primary HMO provider and he/she will refer to other HMO specialists. If treated with providers not participating in the HMO, costs are never covered except for in emergency cases. HMOs require a referral from your primary doctor to see any type of specialist.

Preventative Care: Yearly check-ups and screenings such as mammograms and immunizations are classified as preventative care and are often covered at 100 percent with most plans. Copays should not be collected for preventative care appointments.

HSA (Health Savings Account): A HSA is a pre-tax savings account that allows you to set aside funds for future health care costs. HSAs are typically paired with high deductibles or consumer directed healthcare plans. An HSA account is not required to be spent in a single year.

HDHP / CDHP (High Deductible Health Plan / Consumer Directed Health Plan): Simply stated, HDHP and CDHP are health insurance plans that use high deductibles coupled with an HSA. This in turn pairs the consumers with more accountability of their health care expenses.

Choosing and being satisfied with your healthcare insurance coverage is getting more and more difficult each year. However, as consumers we know how important it is to have health insurance coverage. On the flipside, we also know how confusing insurance terms and policies can be, and let’s not forget – COSTLY! At Hand to Shoulder Center of Wisconsin, we take insurance coverage very seriously. Nonetheless, no matter how intense our knowledge of insurance is, it is ultimately the consumer’s (policy holder’s) responsibility to know the benefits and/or restrictions of their policy. We highly recommend all new patients and previous patients verify their insurance coverage before their initial appointment at Hand to Shoulder Center. This can easily be done by calling the eight hundred number on the back of your insurance card and providing our providers’ Tax ID number. With this Tax Id number the customer service representative will be able to tell you if our orthopedic physicians are in-network with your plan. By doing so, it will potentially safeguard you against any unforeseen cost surprises!

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