Understanding Your Insurance Benefits
When it comes to knowing your healthcare costs, having a comprehensive understanding of your health insurance benefits is essential. However, understanding terms like coinsurance, co-pay and deductible, along with knowing when services are covered and when they're not, can seem like you're learning a different language.
To help you understand your health insurance benefits, we've provided a list of common health insurance terms and conditions.
Common health insurance terms
Coordination of Benefits: Often referred to as COB. This is information you need to provide to your insurance company to determine which plan has the primary responsibility. Sometimes two insurance plans work together to pay claims for the same person. That process is called coordination of benefits.
Explanation of Benefits: Often referred to as an EOB. This is a statement from your insurance provider explaining how and why a claim for medical services was or was not paid.
Claim: Information the healthcare organization submits to your insurance provider to be reimbursed for the services you were provided. It is used by the insurance provider to process payments toward your care.
Secondary insurance—If you have more than one insurance plan, please let us know. After your primary insurance pays its portion, we’ll send a claim for the remaining balance to your secondary insurance provider. The amount left over, if any, is what you pay.
Out-of-Pocket Expenses Explained
Out-of-pocket expenses refer to the costs not covered by your insurance. This is what you pay for your healthcare on your own. This amount varies depending on the benefits offered by your insurance plan.
Based on your plan, there is an annual maximum out-of-pocket amount you will pay. After you reach this maximum, your insurance usually covers everything at 100% for the rest of the year. Your out-of-pocket expenses can include:
Copayments (or copays)—This is a fixed amount that is part of the portion you pay for care and is paid at the time of service. You may have different copays for different visits types, like primary care, specialists, emergency room or hospitalization.
Coinsurance—This is the way you and the insurance company split the cost of care. Your coinsurance is the portion, or percent of the cost, you pay after your insurance company pays its portion. Coinsurance starts after you have met your deductible.
Deductible—This is a pre-set amount that you are responsible for paying before your coinsurance begins. Every plan is different, but generally you will pay for all of your medical care up to this amount.
Non-covered services—This refers to services that your health insurance plan does not cover. This may be because your plan excludes the service, the service is not considered medically necessary, or the service is considered investigational or experimental.
Need additional assistance?
While these explanations are a good start, we realize we haven't covered every question you may have. Contact one of our financial counselors to discuss your insurance benefits further. They can help you figure out your level of coverage, as well as any out-of-pocket expenses you may be responsible to pay. Additionally, they can connect you with resources to help you pay your healthcare expenses if you qualify.
Our counselors are available Monday - Friday, 7:30 a.m. - 4 p.m.