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Health Insurance "Alphabet Soup" - What Do All Those Initials Mean?

Health Insurance "Alphabet Soup" - What All Those Initials Mean

When dealing with health insurance, you may be confronted with enough alphabet to write a book. Medical and health insurance companies all have terms that are commonly used and usually shortened to acronyms; HMO for health maintenance, for example. These health insurance acronyms can be confusing, and in today's health care climate, it's important to know what you're talking about. Here are some commonly used acronyms.

Coinsurance: The amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible is co-insurance. Coinsurance rates are usually expressed as a percentage; for example, if the insurance company pays 80 percent of the claim, you pay 20 percent (an 80/20 plan).

Coordination of Benefits: A process to avoid duplication of benefits when one is covered under more than one group plan; for example, a child covered under both spouse's health insurance plans. Benefits under the two health insurance plans usually are limited to no more than 100 percent of the claim.

Copayment: "Co-pay". The fee paid by the insured upon receiving medical services (for example, $5 for every visit to the doctor, $5 for each prescription drug). The insured pays the co-pay and the insurance company pays the rest.

Covered Expenses: There are medical expenses that health insurance plans will not pay. These exclusions are specified in the health insurance policy. Some plans may not cover prescription drugs. Others may not pay for mental health care. Cosmetic procedures are not covered. Covered services are those medical procedures and goods that the insurer agrees to pay for.

Deductible: The amount of money you must pay each year to cover your medical care expenses before your insurance policy starts paying. If your policy specifies a $250 deductible, for example, the health insurance plan begins paying after the insured has paid $250 of eligible expenses.

Exclusions: Specific conditions, circumstances, goods or services for which the policy will not provide benefits. Medical procedures that are strictly cosmetic, for example, are not covered by most health insurance plans, nor are elective abortions usually covered.

Explanation of Benefits (EOB): A statement from the health insurance company stating what charges are incurred and billed, the amount that is eligible under the health insurance policy, the amount paid by insurance. For any charges denied, a brief reason for the denial should be given.

HMO (Health Maintenance Organization): These are prepaid health plans. For a monthly premium the HMO covers doctors' visits, hospital stays, emergency care, surgery, checkups, lab tests, x-rays, and therapy. You must use the doctors and hospitals designated by the HMO as "in-network".

In-network Provider: A health care provider that is contracted with the insurance plan to provide goods or services to the health plan members, usually at a reduced rate.

Managed Care: Methods and processes designed to manage health care costs, use, and quality of the health care delivery system. All HMOs and PPOs, and many fee-for-service plans, have managed care.

Maximum Out-of-Pocket: The most money you will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums. Typically the health insurance company will begin to pay 100% of eligible charges after the insured pays this amount.

Noncancellable Policy: A health insurance policy that guarantees you can receive insurance, as long as you pay the premium. It is also called a guaranteed renewable policy.

Out-of-Network Provider: A provider (doctor, hospital, pharmacy, equipment company, etc.) that is not contracted with a health insurance plan. HMOs usually do not pay for out-of-network providers. PPOs may pay, but usually at a lower rate than paid to preferred, or "network" providers.

PPO (Preferred Provider Organization): A combination of traditional fee-for-service health insurance plans and an HMO. When you use the doctors and hospitals that are part of the PPO, or "in-network" providers, you can have a larger part of your medical bills covered. You can use other doctors, but at a higher cost to you. For example, a PPO plan may cover 90-100% of eligible expenses for an "in-network" provider, but only 70% for providers who are "out-of-network".

Preexisting Condition: A health problem that existed before the date your health insurance became effective. Preexisting conditions may be excluded permanently or may be eligible after a certain period of time.

Premium: The amount you or your employer pays in exchange for health insurance coverage.

Primary Care Provider: Often a family physician or internist, or a pediatrician for a child, that monitors and treats a plan member's health. In most managed care plans, specialty care requires referral by the primary care provider.

Provider: Any person (doctor, nurse, dentist) or institution (hospital, clinic, durable medical equipment company) that provides medical care, services or goods.

Third-Party Payer: Any payer for health care services other than you. This can be an insurance company, an HMO, a PPO, or the Federal Government.

Hope this helps you understand some of the health insurance jargon.

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