2. What is Health Insurance?
• Health insurance is a type of
insurance coverage that covers
the cost of an insured individual's
medical and surgical expenses.
• In countries without universal
health care coverage, such as the
USA, health insurance is
commonly included in employer
benefit packages and seen as an
employment perk.
3. Why Do I Need Health
Insurance?
•As medical care advances, health
care costs also increase. The purpose
of health insurance is to help you
afford your care. It will protect you
financially, in the case of a serious
medical issue. For some, health
insurance may use their benefits for
the occasional doctor’s visit or minor
illness. Others may need the
coverage and protection in the case
of a catastrophic medical issue.
4. What Should I Look For?
You many need some help narrowing
your choices in the marketplace.
Consider the following 4criteria
when making your choice:
•
Health benefits: Which plan provides the
must-have benefits you've identified?
•
Costs: Which plan falls within your budget
when it comes to premium, deductible,
copayments, and coinsurance?
•
Physician network: Do you have a doctor or
doctors that you want to keep?
•
Prescriptions: Does the plan cover your
medications?
5. Common Terms- Subscriber
• Deductible: The amount of money you must pay each year to cover eligible
medical expenses before your insurance policy starts paying.
• Dependent: Any individual, either spouse or child, that is covered by the
primary insured member’s plan.
• Out-of-pocket maximum: The most money you will pay during a year for
coverage. It includes deductibles, copayments, and coinsurance, but is in
addition to your regular premiums. Beyond this amount, the insurance
company will pay all expenses for the remainder of the year.
• Premium: The amount you or your employer pays each month in exchange
for insurance coverage.
6. Common Terms- Subscriber
(cont.)
• Participating Provider: Generally, this term is used in a sense
synonymous with Network Provider.
• Preauthorization/Precertification: These are terms that are often
used interchangeably, but which may also refer to specific processes
in a health insurance or healthcare context.
• Primary Coverage: If a person is covered under more than one
health insurance plan, primary coverage is the coverage provided by
the health insurance plan that pays on claims first. See also, COB.
• Referral: The process through which a patient under a managed care
health insurance plan is authorized by his or her primary care
physician to a see a specialist for the diagnosis or treatment of a
specific condition.
7. Common Terms- HCP
• Benefit: The amount payable by the
insurance company to a plan member for
medical costs.
• Benefit year: The 12-month period for which
health insurance benefits are calculated, not
necessarily coinciding with the calendar
year. Health insurance companies may
update plan benefits and rates at the
beginning of the benefit year.
• Claim: A request by a plan member, or a plan
member's health care provider, for the
insurance company to pay for medical
services.
• Copayment: One of the ways you share in
your medical costs. You pay a flat fee for
certain medical expenses (e.g., $10 for every
visit to the doctor), while your insurance
company pays the rest.
8. Common Terms- HCP
(cont.)
• Coordination of benefits: A system used in group
health plans to eliminate duplication of benefits
when you are covered under more than one group
plan.
• Explanation of benefits: The health insurance
company's written explanation of how a medical
claim was paid.
• In-network provider: A health care professional,
hospital, or pharmacy that is part of a health plan’s
network of preferred providers. You will generally
pay less for services received from in-network
providers because they have negotiated a discount
for their services in exchange for the insurance
company sending more patients their way.
9. Common Terms- Payer
• Buy and Bill: This is a method of acquisition
where the MD will purchase the medication
wholesale and bill the insurance for both the
drug and administration.
•
Coinsurance: A portion of the bill for a
medical service, that is not covered by the
patient's health insurance policy and
therefore must be paid out of pocket by the
patient. Coinsurance is calculated by a
percentage.
• Deductible: The amount of health care
expenses a patient must pay before their
health plan begins to pay for costs
associated with a medical service. These
amounts can change every year.
• ICD-9: ICD Codes, International Classification
of Diseases, are maintained in the United
States by the CDC, and internationally by the
World Health Organization.
10. Common Terms- Payer
(cont.)
• Lifetime Max: This is the maximum amount that
your insurance company will pay during your
lifetime. It is important to note that some plans also
have an annual maximum.
• Medical Policy: Guidelines that detail when certain
medical services are considered medically necessary
by a payer, and whether or not they are considered
investigational.
• Pre-Certification: Verification that a
service, supply, therapy or medication is covered
before rendered. It may also specify the
conditions, medical setting, length of time or any
other limits of your coverage.
• Out of Pocket Maximum: The out-of-pocket
maximum is the highest amount a health plan
requires a patient to pay towards the cost of their
health care.
11. Wrap-Up/Questions
• When dealing with your HCP or Payer, be clear and concise with all questions
relating to your care and applicable benefits.
• Document all information received from payers along with the reference
number of your call. This number can be referred to in the future should there
be an issue with your coverage.
• If it doesn’t sound right, it probably isn’t. Ask for clarification.
• Google is always your friend. Many clinical policies can be found online, along
with benefit details of plans.
• Questions?
