Understanding Insurance: Basic Terms

Understanding Insurance
Basic Terms

      Hey everyone, Kelcey here! After working for Excel Chiropractic for over three years and being responsible for all things insurance related, you can probably guess that I get a lot of people asking me for help in explaining their insurance benefits. I regularly get calls from family and friends, asking for one thing or another to be explained. I know insurance can be confusing, so I thought I would create a series of blogs that would allow me to share what I know and hopefully answer some common insurance questions.

** Please Note: I am not an insurance expert. All terms and actions are explained to the best of my abilities and in accordance to Excel Chiropractic’s policies and procedures (aka: very by the book, we love to follow the rules here!)

***Also Note: These are basic terms and explanations. I will explain what occurs with the MOST COMMON insurance plans. There are outliers that exist to throw everyone for a loop. Ultimately, there is no guarantee of benefits and they will be fully determined when the claim is processed (aka: we will abide to the benefits presented to us when we receive the claim back from the insurance company. This means your benefits may be different from what we were originally told.)

Basic Terms:

·         In-Network: Refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider, because those networks provide services at lower cost to the insurance companies with which they have contracts.

o   Sometimes referred to as a preferred provider by insurance companies

·         Out-of-Network: Refers to a patient seeking care outside the network of doctors, hospitals or other health care providers that the insurance company has contracted with to provide care.

o   Often, insurance companies do not hold benefits for out-of-network providers, leaving the patient responsible for the bill in full.

·         Co-payment or co-pay: A set amount that the insured (patient) is required to pay at the time of services. This payment may or may not cover all services you receive in the office

o   Some services, for example: x-rays, may be subject to your deductible. While we are able to tell you what will and won’t be covered in our office, if you visit a larger organization (such as Avera or Sanford), you may want to review your insurance coverage before being seen.

·         Deductible: A certain amount of money the insured is required to pay out of their pocket before the insurance company will begin to pay claims.

o   Most family health insurance policies have both individual deductibles and family deductibles.

§  Individual Deductible: A certain amount of money each individual insured on the insurance policy must pay. Once met, the insurance company will begin to pay on services for that individual only, but not for other family members.

§  Family Deductible: Each time an individual within the family pays toward his or her individual deductible, that amount is also credited toward the family deductible. If the family deductible is met, health plan benefits kick-in for every member of the family whether or not they’ve met their own individual deductibles.

o   Most deductibles are annual, meaning they last for the contracted plan year. They will reset at the beginning of the next contracted year, requiring the insured to pay out of pocket once again.

o   There are typically separate deductibles for in-network and out-of-network services.

·         Co-Insurance: Defined as the insured’s share of the cost for health care services. If is usually figured as a percentage (like 20%) of the insurance company’s allowed amount of charged services. A co-insurance comes into effect once the individual or family deductible has been met.

o   Example: If the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount (80%).

·         Out-of-Pocket Max: The most an insured will pay during a policy period before their health insurance or plan starts to pay 100% for covered health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the health benefits.

o   Like with the deductibles, there is usually an individual and a family out-of-pocket max.

o   Commonly, there are separate out-of-pocket maximums for in-network and out-of-network services.

These are the most basic terms that a provider’s office will deal with on a daily basis. If you have any questions or concerns regarding your insurance policy and how it works, please do not hesitate to give me a call at the office. I highly suggest having a basic idea/understanding of your insurance coverage before receiving care at any provider’s office. 

If you would like to see a post about a certain insurance term/question, please do not hesitate to let me know. I will do my best to answer any questions or explain any issues!