Insurance Terms and Coverage Explained
Insurances can be very confusing when it comes to healthcare, but don’t worry. At IVC, we go over your insurance coverage to help you understand what they will cover for your medical procedures in our office. So when you leave our office, you will have a better understanding of the cost for treatment as well as budgeting and financing for your health.
Do I pay monthly, or yearly?
Premiums, those are set amounts that individuals pay each month, to have insurance coverage. Think of it like your electric bill, you need to pay the bill each month to have electricity in your house. A premium works the same way; it’s a set amount of what you pay each month.
Deductibles –whatever that means
Next is your deductible. Deductibles are amounts that an individual will have to pay before their insurance will even start to pay. Sometimes depending on the benefit plan, insurances will waive the deductible and just make you pay coinsurance. Deductibles can be tricky, because oftentimes insurance plans can have a family deductible, individual deductible or even both. Deductibles range in amounts and oftentimes people think that once they have met this amount they will be covered at 100%, but it is often not the case.
Coinsurance is usually the amount you have contracted with the insurance to pay for your visits. Insurances pay a certain amount and leave the patient with their contracted or co-insurance amount. Let’s look at the 80/20 plan, insurances would pay 80% of the bill and the individual would be left with 20% of the bill. Coinsurance seems pretty self-explanatory, but there are more small facts inside of a plan. Insurance plans can range all over- from a non-covered benefit, meaning the patient would be most likely left with the full amount, to having 100% of their treatment or plan covered.
Out of Pocket Max, or Max out of Pocket?
The Out of Pocket Max is another limit that you have worked towards throughout the year before the insurance will pay 100% of your procedure costs. Out of Pocket Maximums can range in the amount you will pay per year. A maximum is typically the most money you would pay for your health care per year. Just think that if you’ve maxed out, you’ve reached your limit.
Out of network benefits or in-network?
Going to the doctors contracted with your insurance is always a smart idea. To have benefits in-network means that your insurance is contracted with a provider and both parties have agreed to negotiated rates. Oftentimes you will end up paying less to go to the contracted provider. To have an Out of network rate, means that your insurance will allow you to go to providers that aren’t contracted with them. However, the provider is not obligated to take that negotiated rate and the patient can be left with their out-of-network percentage and the adjustment amount that typically is written off by a contracted provider. Most of the time, insurances will pay a lower percentage of your visit, as compared to a visit paid at a higher rate with a provider that is in network.