Common Insurance Term Definitions

Insurance plans are continuously evolving, and not getting any less complex. It’s best to arm yourself with as much knowledge of the nuts and bolts or insurances as possible. In the search for a health care plan or even when reviewing the plan from your employer, it is imperative to understand the terms used in the plan benefits. Getting to know the foundational terms of insurance plans and how they work can help in selecting a plan that is right for you. This will minimize the potential of surprise medical bills from not fully discerning the benefits of a plan. 

These are the most common terms that determine how much a plan will cost: 

Deductible – a fixed amount the patient is responsible for paying before the insurance company begins to pay for services.

Co-pay – a fixed amount paid on each date of service. However, if a patient has a deductible, the deductible must be met first.

Co-insurance – Unlike co-pay, this represents the percentage of cost of which the patient is responsible. Again, this is after any deductible is met. A patient that has a 10% co-insurance would pay $10 on a service that costs $100.

Out-of-Pocket Maximum – is a fixed amount that is the highest amount a patient can be expected to pay per year. The insurance plan will pay 100% when this is met.

Premium – This is the monthly payment made to participate in the insurance plan, which is separate from any deductibles, copays, or coinsurance. 

All of these costs should be considered together in order to determine the quality of a plan. For example, a low with low premiums may look appealing, but can end up being pretty expensive if you factor in a high deductible and a co-insurance. 

Here are some other useful terms for reading through insurance plans or paperwork from insurances:

Claim – a request made to the health insurance company by a plan member or the member’s provider to be paid for services

Provider – the medical professional that is giving the treatment

Date of Service – the date the treatment or visit occurred

Explanation of Benefits – This is a notice the insurance company sends out of how a claim was paid out to the provider. 

Health Savings Account – This is a feature of some higher deductible health plans to put away pre-tax dollars to use towards health care expenses. 

Flexible Spending Account – This is similar to a Health Savings Account, but typically does not roll over year to year and must be spent within the plan year.

In Network – The network of an insurance plan is the list of providers that are preferred by the plan. Usually, the insurance plan will provide this list or a provider can tell you which insurances they are in network with. Some insurance plans do not cover any services outside of the network, and some will cover services outside of the network but at a higher cost. You want to check in advance if the providers that you see on a regular basis are in the network.

Out of Network Benefits – An insurance plan will typically have a separate (and higher) set of out of pocket costs for a provider that is out of network as opposed to a provider that is in network. It is extremely important to know who is in and who is out of network to avoid unnecessary costs. Sometimes, there are no out of network benefits at all and you would be charged the full amount for services. Even in a hospital, you can be treated at an in network facility by an out of network provider and get an out of network bill. Crazy, right?

Cash pay – Some providers chose to not work with insurances and will charge a flat rate for their services.

Selecting an insurance plan is definitely not easy. It seems as though the plan members are paying more and more money, and getting less and less covered. Hopefully, getting familiar with some of these terms will make the process a little bit less of a burden. At CafePhysio, we deal with strictly cash pay service currently, so you could always bypass the system completely and come see us! 

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