20 Health Insurance Terms to Learn


screen-shot-2017-01-04-at-9-20-29-amDoes insurance confuse you? You’re certainly not alone.

KETV, a news station based in Omaha, shared 20 health insurance terms that can help you take control of your coverage again. You can see the full definitions and slideshow here.

  1. Allowed Amount: Also known as “eligible expense”/”negotiated rate”/”payment allowance;” it means the maximum amount health services are based on/are covered by the insurance company
  2. Balance Billing: The provider’s bill that gets sent you to after the insurance company pays their portion
  3. Claim: The bill that gets submitted to your health insurance company
  4. Co-Insurance: The percent that you pay in addition to whatever deductible you have.
  5. CoPay: The amount you pay at the time of each healthcare visit.
  6. Deductible: The amount you pay before receiving your benefits. Basically, when the insurance company says, “We’ll pay anything over $500,” then you know $500 is your deductible.
  7. Donut Hole, Medicare Prescription Drug: The coverage gap that occurs after you spend a certain amount on covered drugs, and you have to pay out-of-pocket for your prescriptions for up to a year. After that year, the insurance company resumes helping you pay.
  8. Essential Health Benefits: The 10 categories that the insurance company must cover.
  9. Excluded Services: The services that your insurance doesn’t need to cover.
  10. Health Insurance Marketplace: A way for anyone to compare health insurance plans based on the filters they choose.
  11. Health Savings Accounts (HSA): “A medical savings account available to taxpayers who are enrolled in a high deductible health plan.”
  12. High Deductible Health Plan: A type of insurance plan that can be combined with a health savings account/reimbursement arrangement.
  13. In– and Out-of-Network: Healthcare offices either have a contract with the insurance company (In-) or they don’t (Out-)
  14. Lifetime Limit: “A cap on the total lifetime benefits you may get from your insurance company.”
  15. Outof-Pocket Maximum: The absolute most you would pay throughout your policy before insurance takes over 100% of the allowed amount.
  16. PreExisting Condition: A health problem that you had before establishing your insurance coverage.
  17. Preferred Provider: “A provider who has a contract with your health insurer or plan to provide services to you at a discount.”
  18. Premiums: “The amount you must pay for your insurance plan.”
  19. Preventive Care: Regular healthcare like checkups, counseling, and screenings.
  20. UCR (Usual, Customary, and Reasonable): The cost of medical services relative to location.

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