Health Insurance & Patient Responsibility

Health insurance plans can be complicated, full of exceptions, exclusions, special provisions, and legal jargon making it difficult to know exactly what you're paying for and what is covered. Policy holders are referred to the member handbook or carrier websites for terms and conditions, coverage information and benefit explanations that are lengthy and almost seem like a foreign language at times. 

Unfortunately, you as patients are responsible for understanding and abiding by the terms of their plan even if you don't fully comprehend the coverage and limitations. There are innumerable policies out there, each with untold numbers of benefit options. Group employers have the opportunity to pick and choose, changing even the tiniest detail for the new coverage year. Even if your card looks the same, the benefits behind that card may have changed.

Below we have a list of common terms associated with health insurance which will hopefully help you navigate the process with more confidence. If you have questions about benefits and coverage, there is a list of accepted insurances under the Insurance tab, along with toll-free numbers for each insurance company.

Language

Deductible:  A deductible is the amount you pay for health care services before your health insurance begins to pay.

How it works: If your plan’s deductible is $1,500, you’ll pay 100 percent of eligible health care expenses until the bills total $1,500. After that, you share the cost with your plan by paying coinsurance.

Coinsurance: Coinsurance is your share of the costs of a health care service. It's usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you've paid your plan's deductible.

How it works: You’ve paid $1,500 in health care expenses and met your deductible. When you go to the doctor, instead of paying all costs, you and your plan share the cost. For example, your plan pays 70 percent. The 30 percent you pay is your coinsurance.

Copay: A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service.

How it works: Your plan determines what your copay is for different types of services, and when you have one. You may have a copay before you’ve finished paying toward your deductible. You may also have a copay after you pay your deductible, and when you owe coinsurance. 

What to Ask at a Doctor's Office

Do not ask "Do you take my insurance?". Medical offices will take most insurances, but your benefits will not necessarily cover expenses at that office.

Instead, ask "Are you in network with my insurance?". This ensures that your benefits will cover your visit and your copay will be minimized.