10 Crucial Health Insurance Terms That You Must Know: Learn Them Before Choosing Your Insurance Plan

Proper knowledge about basic health insurance terminology is essential to choose a health care plan to meet your needs and budget. A recent study published in the Journal of Health Economics reported that only 14% of those polled could identify basic health insurance terms and that only 11% could determine the price of a four-day hospital visit after being given a hypothetical plan.
As about 48 million uninsured Americans are expected to purchase coverage to meet the requirements of Obamacare, lack of proper understanding about the basic terms can become a big issue. The co-author of the study, George Loewenstein has pointed out that other research has shown that people make very bad health plan choices due to their lack of awareness of the basic terms. You could end up with a plan that costs a lot, but lacks the benefits you require.
Educate Yourself to Make the Right Choice
Here are the ten important health insurance terms that you must know when you enroll in a plan through the health exchange:
This is the amount you must pay for your health care plan. This amount will vary by plan and can be paid monthly, quarterly or yearly. For example, the average monthly premium for Obamacare is $328. But the amount would go below and above it depending on the type of plan (bronze, silver, gold, or platinum and catastrophic coverage), state, and community.
Allowed Amount
The maximum amount based on which your insurance provider will make the payment for your covered health care services. This term is also known as "eligible expense" or "negotiated rate" or "payment allowance". If the health care provider bills you more than the allowed amount, you have to pay the balance on your own. This is known as balance billing. Suppose the provider charges $200 for a health care service and the allowed amount is $150. The provider will bill you for the remaining $50.
The amount you should pay for the covered healthcare services before your plan begins to pay. For example, if your deductible is $700, the insurer will not pay for any health care service you are provided with until your costs are more than $700.
The co-payment or co-pay is a fixed amount you need to pay whenever you are provided with the covered health service. The amount will vary according to the type of service. For instance, if your co-pay is 20 dollars for an office visit, you would have to pay that amount for each visit. Your plan will cover the rest.
In a health care plan, you may need to pay a percentage of the allowed amount for a health care service, which is known as co-insurance. You have to pay this amount in addition to your deductible and the plan will pay the rest of the allowed amount. Imagine that the allowed amount is $200 for a doctor visit and the co-insurance payment is 20%. If you have met your deductible, you will need to pay $40 for the doctor visit and your insurer will pay $160.
In- and out-of-network
A health care provider who has contracted with the health insurance company is an in-network provider and one who does not hold such a contract is an out-of-network provider. Certain health plans like HMOs do not reimburse for out-of-network services and you must pay fully for these health care services. Some health plans cover out-of-network providers too. In-network co-payments and co-insurance are much lower than out-of-network payments.
Out-of-pocket maximum
The out-of-pocket maximum or limit is the most you pay over a policy period (normally one year) until your insurer begins to pay the allowed amount. This total does not include premiums, balance-billed charges or costs for non-covered services. Certain health plans do not include co-payments, deductibles, co-insurance, out-of-network payments, or other expenses in this amount, so you need to know your plan coverage well. Medicaid and CHIP (Children's Health Insurance Program) include premiums in this limit. The maximum out-of-pocket costs for a marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Essential Health Benefits
The Affordable Care Act insists that, starting 2014, certain health plans (offered in the individual and small group markets, inside and outside of the marketplace) must cover a comprehensive package of health care services and items known as Essential Health Benefits. Only insurance policies thyat cover essential health benefits are certified and offered in marketplace. States are also expanding their Medicaid programs to offer these benefits to people newly eligible for Medicaid. Essential Health Benefits have to include products and service from at least the following ten categories
  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services including oral and vision care
Preventive Services
The health care services provided to prevent illness, disease, or other health problems come under preventive services and include screenings, check-ups and patient counseling. Most health plans offer coverage for a set of preventive services free of cost, including shots and screening tests. The private insurance plans in the marketplace cover this type of service without co-insurance, co-pay or even meeting the deductible.
A request for payment submitted to your health insurer after receiving the covered health care services. Normally, the health care providers submit this to the insurance company with the help of a medical claim billing specialist who prepares and reviews all claims based on the rules and regulations of the relevant health care plan before submission.
Open enrollment is Obamacare runs through March 31, 2014. Consumers need to educate themselves on the basic terminology to purchase a suitable healthcare plan. Patient eligibility verification for physicians' practices should involve checking all payable benefits, patient details, pre-authorization number, co-pays, co-insurance details, deductibles, patient policy status, effective dates, type of plan and coverage details, plan exclusions, claims mailing address, referrals and pre-authorizations for proper reimbursement. The billing specialists in a professional medical billing company have in-depth knowledge of all aspects of health insurance to ensure accurate claim submission for their clients.
By Gosheven Hamilton

10 Crucial Health Insurance Terms That You Must Know: Learn Them Before Choosing Your Insurance Plan Rating: 4.5 Diposkan Oleh: sakerso mawon
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