Ten most common health insurance terms and definitions you’ll need to know

Confused Black Woman

By Yolanda Spivey

HEALTH INSURANCE!!! That’s all everyone is talking about these days, especially since the open enrollment period to apply is within the next few weeks.

From November 15, 2014 to February 15, 2015, you’ll have a chance to enroll in  a health care plan by logging onto www.healthcare.gov.  While Americans log on to select a health insurance plan that is best for them, many will find the language of health insurance hard to understand.  But it is important that consumers have a basic knowledge of the industry’s terminology.

Here are ten of the most common insurance terms and definitions you’ll run across as you make your health insurance selections in the Health Insurance Marketplace:

  1. Premium:  This is a flat fee you pay to have your insurance policy in place.  You usually pay this on a monthly basis.
  2. Deductible: The amount of money you must pay each year to cover health services before your insurance policy starts paying.  Example: A $500 yearly deductible must be paid by you before your insurer starts to pay.
  3. Co-Pay:  A flat fee you pay for certain medical expenses, while your insurance company pays the rest.  Example:  You paying $20 for every doctor’s visit or $50 for a visit to a specialist.
  4. Co-Insurance:  A percentage of what you’ll pay and what an insurance company will pay after the deductible is met. Example: You pay 20% of a claim while the insurance company pays the remaining 80%.
  5. Out-of-pocket limit/ maximum:  The MOST money you will pay during a year for coverage.  It includes deductibles, co-payments, and co-insurance in addition to your regular premiums.
  6. Payer– The insurance company/ carrier you’ve selected.
  7. Provider– Any person whether it’s a doctor’s office, dentist, nurse, hospital, clinic, etc… that provides medical care.
  8. Preferred Provider Organization (PPO)– A health insurance plan that allows you freedom of choice to get care from both in-network and out-of-network providers.  When you use providers in-network, you receive the highest level of benefits.
  9. InNetwork Provider–   A health care professional, hospital, or pharmacy that is part of a health plan’s network of preferred providers.  You will pay less and receive the maximum amount of services.
  10.  Health Maintenance Organization (HMO)– A health care financing and delivery system that provides comprehensive health care services for enrollees in a specific geographic area. HMO’s require the use of specific, in-network plan providers and usually you have to go to your designated doctor for permission to seek other essential services.



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