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Understanding Your Health Insurance

It is important that you learn and understand the basics of health insurance and how it works.

How Insurance Billing Works 

Understanding Health Insurance

Commonly Used Terms

Understanding Health InsuranceDeductible: The amount you are responsible for paying for covered medical expenses before your health insurance plan begins to pay for covered medical expenses each year.

Coinsurance: Shared costs between you and the health insurance plan. For example, you pay 20 percent of costs and your plan pays 80 percent. These percentages may be different from plan to plan. Some plans may not have coinsurance.

Copayment: The payment you make, usually a fixed dollar amount such as $15, each time you visit the doctor or fill a prescription medication. Not all plans have copayments. These typically do not accumulate toward the deductible.

Out-of-pocket maximum: The most you will have to pay for covered medical expenses in a plan year through deductible and coinsurance before your insurance plan begins to pay 100 percent of covered medical expenses.

How Much Will You Pay Out of Your Pocket?

Your premium + your deductible + any coinsurance you must pay (up to your out-of-pocket maximum) + any copayments = the most you will pay for healthcare each year (for covered services).

Out-of-pocket maximums can be different depending on your plan and family size. Once you reach the out-of-pocket maximum, insurance pays for 100 percent of your medical care (for covered services).

How you reach that out-of-pocket maximum is based on how much you pay for your medical care up front. This depends on your deductible and coinsurance percentage. The higher your deductible, the lower your monthly premiums will be, because you are willing to pay for some of your care up front.

It is important to understand that premiums are costs that you pay regardless of whether you use medical services. Deductibles only become expenses once they are incurred.

Understand the plan that you have purchased

There are many things to consider when choosing a health insurance plan. You want a plan that will meet your needs for types of coverage, access and dependability at a reasonable cost.

Do I want basic or more comprehensive coverage?

Some insurance plans offer basic coverage that protects your finances in the event of an illness or injury resulting in a hospital stay. These types of plans typically have a lower monthly premium, but you are responsible for doctor visits.

Other health insurance plans offer more doctor visits to include healthcare, maternity benefits, prescription drug benefits, eye care and routine doctor visits. These types of plans tend to have a higher monthly premium and may be more appropriate for those who may use their insurance benefits on a regular basis.

Is my doctor or hospital covered by the plan?

You need to check the insurance plan's network provider directory to confirm that your doctor or hospital is included in the plan's network. If you use doctors that are in the plan's network, you will receive the highest level of benefits.

Does the health insurance plan cover me if I travel?

Some plans have provider networks that are based on where you live. If you travel outside of that area, you are typically not covered by your health insurance plan.

Does the plan work with a health savings account (HSA)?

Some high-deductible health insurance plans work with tax-favored health savings accounts that can be used to pay for certain qualified medical expenses.

 
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