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Helpful Definitions

Here are a few of the frequent insurance terms you might hear.

Deductible – A deductible is the amount you will pay before the insurance carrier will pay. This does not include any applicable co-pays, coinsurance or non-covered services.

Coinsurance – After the deductible is paid, you and the insurance carrier share in future payments. This is called coinsurance. It is usually a percentage.

Out of Pocket – The out of pocket is the maximum dollar amount you will pay of your eligible expenses. This is usually on a calendar year basis.

Co-pay – A co-pay is a fixed dollar amount that you will pay a provider for a specified service. It can also apply to prescription drugs.

Health Savings Account – this is commonly referred to as an HSA. This is an account set up through an IRS approved trustee or custodian (which can be a bank.) Funds you contribute to the account can be used for eligible medical, dental and vision expenses as outlined by the IRS. Your employer can also make contributions to your account.

Patient Protection and Affordable Care Act (PPACA) – This is commonly referred to as the Affordable Care Act or the ACA. The initial effective date of the ACA was March 23, 2010 and includes the implementation of a set of rules intended to increase access to healthcare at affordable premiums. The ACA also includes many changes that have been made to individual health insurance, group health insurance, Medicaid and Medicare.

(EOB) Explanation of Benefits – Claims are processed by the insurance company and an EOB is given to the insured to show how the claim was adjudicated. Some of the information the EOB will show is the total amount charged, any discount applied due to network contracting, the amount that is applied to your deductible or coinsurance as well as any monies paid to the provider.

Medicare – Medicare is health insurance for people age 65 and older, people under age 65 with certain disabilities and people of any age with End-Stage Renal Disease (ESRD.)

     There are four parts to Medicare.

  • Part A helps cover hospital services.
  • Part B covers medical services such as physicians' services, outpatient services and preventive care.
  • Part C is a Medicare Advantage Policy
  • Part D is Prescription Drug coverage

Part C and Part D are run by Medicare-approved private insurance companies.