Insurance Terms Glossary
The amount you must pay for medical expenses before your health insurance starts paying.
The percentage paid by the insurance company after you pay the deductible. Example: Your health insurance pays 70%, you pay 30%. The insurance company pays 70% coinsurance, you pay 30% coinsurance.
Annual Coinsurance Maximum
After paying your deductible and after paying your coinsurance (typically 20% or 30% of medical expenses) to a certain dollar amount, your health insurance will pay 100% for the remaining calendar year. Example: After you pay your deductible, your health insurance pays 70% of medical expenses and you pay 30%. Once you reach the coinsurance maximum, you no longer pay 30% of medical expenses because the health insurance pays 100%.
This is the most the health insurance will pay out over your lifetime.
When you visit a doctor in their office they typically bill the health insurance company for an "office visit." Most health insurance plans pay office visit expenses at the coinsurance (typically 70% or 80%) after the deductible. Some health insurance plans pay office visit expenses at the coinsurance but waive the deductible. Some health insurance plans pay office visit expenses in full, after a copay (typically $25 or $30).
Preventive Care is typically defined as routine exams, immunizations, well child care, and cancer screenings. Not all plans cover preventive care.
Diagnostic Lab and X-Ray
When your doctor orders tests involving laboratory or imaging services such as x-ray, CAT scan, etc. these services are typically paid at the coinsurance (typically 70% or 80%) after deductible.
When you visit a chiropractor for spinal manipulation or other services, these expenses are typically paid at the coinsurance (70% or 80%) after the deductible. Most health insurance plans limit the number of chiropractic visits/services to 10 or 12 per year. After this, additional visits are not paid by the health insurance plan.
When you receive care from a hospital (inpatient or outpatient services), these expenses are typically paid at the coinsurance (70% or 80%) after the deductible.
When you receive care from a hospital emergency room, these expenses are typically paid at the coinsurance level (70% or 80%) after the deductible. Most health insurance plans also require you to pay an additional copay (typically $100) for each emergency room visit. Some plans waive this additional copay if you are admitted to the hospital through the emergency room.
About half of all prescription medications filled in the United States are filled with generic medications. Generic medications are much less expensive than brand name medications. A generic medication is equivalent to the corresponding brand name medication. Drug manufacturers are permitted to sell a generic version of a medication after the patent expires for the brand name medication (typically 20 years after the brand name medication was registered). Health insurance plans typically provide better payment for generic medications as an incentive for you to ask for the generic version. Some health insurance plans do not pay for prescription drugs.
Brand Name Medications
Brand name medications are more expensive than generic medications. Most health insurance plans create a limited list of brand name medications that they will pay for. Many health insurance plans also provide less coverage for brand name medications than for generic medications. Some health insurance plans do not pay for prescription drugs.
Non-Preferred Brand Name Medications
Most health insurance plans create a limited list of brand name medications they will pay for. If your brand name medication is not on this list, it might be paid at a lower level under "Non-Preferred Brand Name Medications." Some health insurance plans do not pay for prescription drugs.
Some health insurance plans cover the cost of maternity, which includes doctor and hospital charges for prenatal care as well as labor and delivery.
Mammography is a specific type of imaging that uses a low-dose x-ray system for the examination of breasts to detect early breast cancer in women experiencing no symptoms and to detect and diagnose breast disease in women experiencing symptoms. Current guidelines from the American Cancer Society (ACS), and the American Medical Association (AMA) recommend a screening mammography every year for women, beginning at age 40.
Outpatient mental health services include visits to a licensed counselor, therapist, or psychiatrist. Inpatient mental health services include admission to a psychiatric hospital. Many plans do not cover mental health services.
Rehabilitation therapy may include physical therapy, occupational therapy, speech therapy, message therapy, cardiac rehabilitation, and chronic pain therapy. Most health insurance plans limit rehabilitation therapy to a certain number of visits per calendar year.
Occupational coverage includes the cost of medical services for job related illness or injury. Some health insurance plans do not cover occupational related medical expenses.
Vision coverage is usually broken into two parts: vision exam, and vision hardware. Vision exam benefits include the cost of a refractive exam used to test vision acuity (20/20, 20/40, etc.). Vision hardware represents the cost of eye glasses or contact lenses. Some health insurance plans do not cover a vision exam or hardware. However, medical issues relating to the health of the eye are almost always covered under the regular medical portion of the health insurance plan.
Go to the insurance company's website to research more information such as a listing of contracted preferred providers, insurance company financial rating, etc.
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