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3: Analyze Your Circumstances

Learn Health Care Language

medical bag

Do you speak health care? There are certain terms you will need to know to understand your explanation of benefits.

How Well Do You Speak Health Care Costs?

Drag each word over the definition. Need more help? Check out the glossary at Health care.gov. Also, make use of the customer help line listed on your insurance card or policy and your human resource representative. These valuable resources can help you understand your costs and save you money.


Preauthorization

Copay

Coinsurance

Lifetime maximum

Exclusions

In-network, preferred, participating provider

Out-of-network facility/provider/specialists

Deductible

Out-of-pocket limit
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The percentage of costs you pay after you've paid your deductible. Your portion is usually the smaller percentage and the insurance carrier covers the larger percentage.
Coinsurance
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The fixed amount you pay to a provider for an appointment, service or medication, whether the deductible has been met or not.
Copay
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The amount you pay before the health insurance plan begins to pay for covered services.
Deductible
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Excluded services, procedures and treatments.
Exclusions
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Using these providers usually saves you money but may limit your choice of providers.
In-network, preferred, participating provider
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The total lifetime amount your policy will pay for services. After meeting this total, your plan will no longer pay for covered services.
Lifetime maximum
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Facilities and providers that are not in your insurer’s network. They might cost more and may not be covered by your plan.
Out-of-network facility/provider/specialists
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The most you pay during a policy period for your share of the cost of covered services. Premiums are not included. The family out-of-pocket limit is usually twice the individual amount. (This means that if two people in the family have met the out of pocket limit, it has been met for everyone in the family.)
Out-of-pocket limit
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Authorization by your insurer for you to receive a service, treatment plan, prescription medication or durable medical equipment.
Preauthorization

Scrutinize coverages for inpatient, outpatient, home health, skilled nursing care and durable medical equipment. Most health care policies will not cover long-term care; these policies are usually purchased separately.

SAM tips

Stay In-Network for Cost Savings

Never assume you are in network. Always check by calling the number on the back of your insurance card. Doctor’s offices deal with many patients and insurance carriers, so make the call for yourself to avoid mistakes and avoid costly surprises.

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