Las definiciones

Coinsurance

The percentage of costs for a covered healthcare service that you’re responsible for paying after you’ve met your deductible.

For example, if your coinsurance is 20%, you’ll pay 20% of the cost of a covered service, while your insurance pays the remaining 80%.

Out-of-pocket Maximum/Limit

This is the most you’ll have to pay for covered services in a plan year.Once you reach this limit, your insurance pays 100% of covered services for the rest of the year. It includes deductibles, coinsurance, and copayments, but not premiums.

Health facilities are not usually aware if you have reached your limit. If you are asked to pay a copay when you know you have reached your max, let the facility know and they will not charge you.

Check if you’ve reached your max through your insurance portal

Network

Group of doctors, hospitals, and other healthcare providers that have agreed to work with your insurance company to provide care at reduced rates.

In-network means your insurance plan is accepted by the doctor and/or facility. Out-of-network typically means your insurance will not cover anything since your plan is not accepted.

Always check with your insurance and the physician/facility to make sure your plan is in-network for ANY medical service (ex. bloodwork, imaging, doctor visit, physical therapy).

Preauthorization/ Prior Authorization

Sometimes, your insurance company requires preauthorization before you can receive certain medical services or medications. This means your doctor needs approval from your insurance company before proceeding with treatment to ensure it’s medically necessary.

Typically, this is handled by the physician. But you can always call your insurance to check if it is required or to check the progress on its review.

Explanation of Benefits (EOB)

This is a statement from your insurance company that explains how a medical claim was processed, including what was covered, what wasn’t covered, and any amount you may owe.

If you believe you were falsely charged by your physician or facility, this is the document you give to their billing department to show what you are accountable for.

Claim

A claim is a formal request made by you or your healthcare provider to your health insurance company for payment of covered medical services. When you receive medical care, whether it’s a doctor’s visit, hospital stay, or prescription medication, the provider generates a bill for those services. This bill is then submitted to your insurance company as a claim.

If your insurance wasn’t charged for a service, you can file a claim on your own by calling your insurance. You can also appeal claims if you believe there was an error.

Medicaid

A government-sponsored health insurance program that provides free coverage to low-income individuals and families who do not have access to healthcare otherwise. Eligibility and benefits vary by state, but U.S. citizenship is typically required.

Typically offers HMO plans, which have the least amount of physicians available in-network. Emergency visits are covered.

If you are eligible for Medicaid, you are typically ineligible for any tax credits in Affordable Care Act-based plans.

Medicare

Federal program for people who are 65 or older, as well as certain younger individuals with disabilities or specific medical conditions.

Has different bundles:

Original Medicare – includes Part A (hospital insurance) Part B (medical insurance).

Can go to any doctor that accepts Medicare. No referral.
Can buy Part D (prescription coverage) separately.

Medicare Advantage (aka Part C) – these include Part A, B, and D.

Need to stick to in-network doctors. Need referral.

HMO (Health Maintenance Organization)

Type of health insurance plan that typically requires members to select a primary care physician (PCP) and get referrals from their PCP to see specialists.

Lowest premium/deductible costs

Have a very limited network of physicians: call your insurance to get a list of providers based on what treatment you need that accept your insurance. Then call the provider that you prefer and make sure they verify your insurance is approved since the list is not always the most updated.

EPO (Exclusive Provider Organization)

Type of health insurance plan that is similar to HMO, but does not require members to select a primary care physician (PCP) or obtain referrals to see specialists.

Coverage is still limited to physicians in-network. Typically greater choice of physicians than HMO, but less than PPO.

PPO (Preferred Provider Organization)

Type of health insurance plan that offers the most flexibility in choosing healthcare providers with more in-network options. Referrals are typically not required for specialist visits.

Members may have the option to see out-of-network providers at a higher cost with some coverage.

Higher choice of providers means higher premiums/deductible plans compared to HMOs and EPOs.

HDHP (High Deductible Health Plan)

Type of health insurance plan with higher deductibles and lower premiums compared to traditional health plans. Typically require individuals to pay higher out-of-pocket costs for medical expenses before the insurance company starts to pay for covered services.

Paired with HSAs.

Gives consumers ability to only pay for when they need treatment and have a safety net in case of an emergency. Relatively healthy individuals who do not need much treatment would find this most optimal in needing to only pay a low premium.

HSA (Health Savings Account)

Tax-advantaged savings account available to individuals enrolled in a HDHP. Funds in the account can be withdrawed tax-free to pay for qualified medical expenses.

– Contributions are pre-tax (money deducted from paycheck before taxes withheld).

– Money in HSA can grow tax-free through forms of investments as long as funds stay in the account.

– Unused funds roll over to next year unlike HSA. Does not expire.

FSA (Flexible Spending Account)

Employer-sponsored benefit that allows employees to set aside pre-tax dollars from their paycheck to pay for eligible medical expenses with tax-free withdrawals.

Unlike HSAs, FSAs are “use it or lose it,” so any funds not used by the end of the year are forfeited. (Some plans may offer a grace period or carryover option)

Unlike HSAs, if you leave your job or change employers, you lose access to your FSA funds.