THE BASICS
Carrier
If you are asked to “check with your carrier”, that simply means you should check with your insurance company or contact us at hrbenefits@ihopkc.org.
Coinsurance
A coinsurance is a varying amount that you pay when you receive care, and is calculated as a percentage of the allowed amount for a service. How this works with your deductible: Typically, coinsurance doesn't kick in until you've met your deductible.
For example: Say you’ve met your deductible of $500. If your plan has a 10 percent coinsurance for every in-network specialist visit, and your recent visit is $100, you will owe $10.
Copay
A copay is a fixed amount that you pay when you receive care. How this works with your deductible: Typically, you don't need to meet your deductible for the copay amount to apply, and the money you spend on copays doesn't count toward your deductible.
For example: If your plan has a $10 copay for every in-network specialist visit, you will owe $10 when you go in—period.
Deductible
Your deductible is what you pay up-front for care and is a set amount for the year. For most services, you’ll have to pay the full cost until you hit your deductible amount. After that, your health insurance kicks in and shares costs for the rest of the year.
In-Network vs. Out-of-Network
Like most things in life, every procedure and visit to a doctor costs something.
When you go to an in-network doctor, your health insurance carrier has pre-negotiated how much a service or procedure should cost. This is called an “in-network rate.”
When you go to an out-of-network doctor, because your insurance carrier does not have negotiated rates, you might be charged more for the same services and care. Your plan will probably require you to pay a larger portion of the cost.
Network
A network is made up of the providers (doctors) and suppliers your health insurer has teamed up with to provide healthcare services.
Premium
The amount you pay for your health insurance every month.
Provider
You probably hear this term a lot. “Provider” is used to refer to a physician or healthcare professional.
THE NITTY GRITTY
Allowed Amount
An allowed amount is the price your plan determines is appropriate for care. When you see out-of-network doctors, your plan’s benefits will be based on this allowed amount. This can vary per network. Check with your carrier and ask for their help in making this definition specific to your people’s plan.
Balance Billing
Balance billing is when you’re asked to pay the difference between what a doctor charges for a service, and the allowed amount that your plan covers for this service.
High-Deductible Health Plan (HDHP)
Like comparing prices at different stores, these plans put the patient in charge of finding care that costs the right amount for them. Deductibles for these plans are typically higher, but in-network cost-sharing is low. If you choose a HDHP plan, it’s usually smart to know you can cover the full deductible at the drop of a hat—just in case something goes wrong.
Out-of-Pocket Max
The out-of-pocket max is the most you’ll pay for care during your plan year before your health insurance begins to pay 100 percent of any allowed amounts.
It’s important to note that this amount does NOT include your premium, balance-billed charges, or healthcare services your plan doesn’t cover.
Preferred Provider Organization (PPO)
With a PPO plan, you can choose which provider you want to see without going through a primary care physician (PCP). This allows for more flexibility with care and covers you (to a point) if you see an out-of-network provider.
Prior Authorization OR Pre-Certification
Your doctor may be required to get permission from your insurance company before they provide you certain services. In these cases, your doctor and insurance will work together to determine whether the services are medically necessary (translation: whether or not your insurance will cover it). If you're out-of-network, sometimes you'll need to help your doctor with this process.