Know the health insurance lingo
Affordable Care Act
The Affordable Care Act, also known as the ACA or Obamacare, is a law that was designed to help all Americans have access to affordable health insurance. It’s generally used by people who pay for their own insurance rather than obtaining insurance coverage through an employer. As part of the ACA, if a household income falls within a certain range, people may qualify for discounts, or tax credits, on government-sponsored health insurance plans. Those credits can then be used toward lowering monthly premiums. With the ACA, you also can’t be turned down for a pre-existing condition.
Benefit
A health service or supply covered under your health insurance plan.
Coinsurance
In most cases, the coinsurance is a percentage of total medical costs you pay after you meet the deductible. With other plans, the most common percentage breakouts are 70/30 or 80/20 (you pay either 20% or 30% of the total costs and the insurance company is responsible for the rest). With the Surest plan, there is no coinsurance to calculate.
Copayments
Often known as “copays” for short, these prices are specific dollar amounts you pay for using routine services—like a doctor’s visit or picking up a prescription—defined by your health plan. You pay these prices until you hit a specified amount in health care spending. This specified amount is factored into your out-of-pocket maximum.
Deductible
A yearly threshold, typically the amount of money that comes out of your pocket before health insurance benefits begin to cover the costs. Some plans have an additional deductible for prescription drugs, and family plans can have both an individual and family deductible. In recent years, many deductibles have been climbing at a steady pace. If you have a high deductible and get sick or injured, you could wind up paying a lot in out-of-pocket costs during your plan year. With the Surest plan, there is no deductible to meet.
Effective date
The day your health coverage starts.
Explanation of Benefits
Also referred to as the EOB, this is an account statement (not a bill) that explains how the insurer reacted to your claim, your available benefits and, if necessary, an explanation of the claims appeal process.
Formulary
Also known as a drug list, this is a list of prescription drug medications your health insurance covers.
Group health plans
Plans provided by your employer, government agency or worker's union, typically more comprehensive than an individual plan. Self-funded and fully insured health plans are two types of group health plans.
Health care provider
Your health care providers are part of your health care team: doctors, nurses, therapists and technicians. Providers are also health facilities, like hospitals and clinics. The Department of Health and Human Services defines a health care provider as “any person or organization who furnishes, bills or is paid for health care in the normal course of business.”
Health maintenance organization (HMO)
A health maintenance organization is a category of health insurance, or type of insurance network, that requires the use of specific, in-network health plan providers. With a health maintenance organization, you may be required to choose an in-network primary care doctor, and generally, you'll also need a referral to see a specialist. Most HMOs don’t provide coverage for care outside the network unless it’s an emergency.
Individual plans/individual health insurance
This category of health insurance isn’t connected to your job and isn’t connected to a government-run insurance program like Medicare, Medicaid or CHIP. You might purchase an individual plan if you work for a company that doesn’t offer health insurance, you’re self-employed or you retire before you’re eligible for Medicare.
When shopping for health coverage, you can buy individual health insurance policies on the exchange. The criteria for plans on the public exchange, or the government health insurance Marketplace, are the same nationwide; plans off the health insurance exchange, purchased from a private insurance carrier or broker, are different depending on which state you live in. With the passing of the Patient Protection and Affordable Care Act (PPACA), all plans must cover essential benefits.
In-network provider
Care or providers who are part of your insurance plan’s contracted network.
Network
Your network is a group of hospitals, doctors, labs, specialists and pharmacists who have a partnership (and contract) with your health insurance company to be part of your insurance plan. Members can try to avoid costly surprises by checking if their provider is in-network before seeking care.
Out-of-network provider
These providers are not part of your insurance plan’s contracted network and, as a result, may cost more than using an in-network provider.
Out-of-pocket costs
Costs you pay for medical expenses not covered by your health plan.
Out-of-pocket maximum (or limit)
The most money you’ll pay in a given year for the health care benefits your health plan covers. Once you hit this number, your insurance company picks up the tab for covered services the remainder of the year, presuming you stay in-network. (Monthly premiums and out-of-network expenses don’t count toward out-of-pocket limits.)
Pre-existing condition
A health problem diagnosed or treated before your health insurance plan goes into effect. Common pre-existing conditions include high blood pressure, diabetes, cancer and asthma.
Preferred provider organization (PPO)
A preferred provider organization is another category, or type, of health insurance. With a PPO, there is often greater freedom than an HMO—meaning you can receive care from in-network and out-of-network providers but will likely pay more for out-of-network care. You usually aren’t required to select a primary care doctor and generally don’t need a referral to see a specialist.
Premium (at Surest, we call these 'paycheck deductions')
This is the amount you pay your insurance company to keep your insurance active and provide you with coverage. In a self-funded (or employer-sponsored) plan, the premium is likely the amount that comes out of each paycheck. Regardless of how often (or how little) you use your plan, this is a fixed amount during your plan year. Think of it like a membership.
Preventive care
Preventive care services are meant to help catch health problems before they become serious health issues. A blood pressure screening, a mammogram and a cholesterol test are all examples of preventive care.
Public insurance
Government-sponsored insurance including Medicaid and Medicare.
Summary of Benefits
Your Summary of Benefits is an easy-to-understand summary of benefits and coverage—your health insurance roadmap.
Summary Plan Description
Also known as the SPD, this is a high-level overview of your health plan—a place to find detailed plan information.