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Here are some terms and definintions you will come in contact with when dealing with health insurance.
Co-pay:
This is the fee you pay for certain medical services or prescription drugs. For example, you go to your dr and they ask for your $15 or $25 copay . This is what the offfice visit will cost you each time you go to see your doctor (depending on your plan) or you may pay $10 to fill a prescription and the health plan covers the balance of the charges.
Coverage in/out a PPO network:
The health insurance plan allows you to use any qualified medical service provider, but offer to save you money by using the PPO network your plan is with. You will usually save money by getting higher benefits, or your Co-Insurance will be lower if you use PPO service providers.
Co-insurance:
The ratio (%) of splitting a bill between the insurance company and you. 80% for the first $5,000 means the insurance company will pay $4,000 and you are responsible for the remaining $1,000.
Deductible:
The dollar amount of covered expenses you are responsible to pay the physician or hospital before the policy will pay any benefits. Deductible Per event means you pay your deductible once for all different services you received per one sickness or accident. So in case your doctor requires you to return for a check of your condition due to the same sickness, you will not pay the deductible again.
Maximum lifetime medical benefits:
The total amount payable by the insurance company for covered medical expenses due to injury or sickness per policy lifetime.
PPO or Preferred Provider Organization:
A network of doctors, clinics, hospitals and related medical service providers who are organized under the PPO to provide health care at a discounted or negotiated rate.
Pre-existing condition:
Any injury or illness which you suffered from or for which treatment was received prior to the date your insurance started.
Prescription Drug Coverage (Rx):
A type of specified expense coverage that provides benefits for the purchase of drugs and medicines prescribed by a physician and not available over-the-counter. Often a plan will provide a prescription drug card that allows the insured to obtain medications by simply paying a co-pay at a participating pharmacy.
Usual and Customary charges:
The amount normally charged by the provider for similar services and supplies and do not exceed the amount ordinarily charged by most providers of comparable services and supplies in the locality where the services or supplies are received.
Qualified service provider:
A licensed doctor, laboratory, nurse or hospital. Many plans will limit you to a list of doctors and hospitals organized under a PPO. This is a list of doctors and other service providers who agree to negotiated (and much lower) rates for their services. They, in exchange get referrals from the insurance company. Better plans allow you to visit any licensed doctor or hospital.
Maximum per injury or sickness:
The total amount payable by the insurance company for covered medical expenses for injury or sickness per medical event.
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