Insurance Terms You Need to Know
The health insurance game is complicated, especially when you’re met with puzzling terminology, protocols you can’t process and a less-than helpful call center representative.
The Insurance Advantage
ADVENT works hard to help you get the most out of your insurance. Our team is available to answer your questions pertaining to services and insurance coverage. We’ll fight for procedure approvals and overturn insurance claims - if needed we'll work with you to develop a payment plan so you can start living better today.
If your new to the insurance game, or need a basic understanding of insurance, we've got the basic plan information and terminology for you.
Your deductible is the amount you'll pay for covered services before your health insurance plan contributes that reset at the end of the insurance service year or calendar year. For example, if you have a $1,000 deductible, your insurance might not start covering their share of your bills until you've paid the $1,000 within the benefit period.
Deductibles will vary by insurance carrier and the structure of the deductible. A deductible may apply to all services, while a different plan's deductible may apply to prescription drug coverage. Plans with a lower deductible typically come with a high premium.
Your co-pay is a pre-determined dollar amount you will pay a healthcare provider for a covered service at the time of the visit. Copayments vary from plan to plan, by service and in-network versus out-of-network. For example, you may have a $50 co-pay for a specialist visit.
In-Network versus Out-of-Network
In-network providers, hospitals, independent practices and pharmacies that are a part of a health insurance plan’s network will typically cost less than services outside-of-network. This cheaper, negotiated rate is due to a discount in exchange for insurance company referrals.
Co-insurance is the percentage of covered services you’re responsible to pay, while your insurance covers the other percentage. For example, if your insurance covers 80%, you’ll be responsible for the remaining 20%.
Typically, if the percentage you're responsible for is lower, the premium is higher.
Maximum Out-of-Pocket Costs
Your out-of-pocket maximum is the maximum amount of money you will pay for covered service during the course of a benefit period. The out-of-pocket maximum varies from plan to plan, but can include co-pays, deductibles and co-insurance. It will never include your premium, balance-billed charges or services your insurance plan does not cover. Once you’ve paid your full out-of-pocket maximum, your insurance will play 100% of the allowed amount for your covered healthcare expenses.
While the world of insurance may be overwhelming, know that ADVENT is here to guide you through the process. You deserve to put your sinus and sleep concerns to bed for good.