Explanation of benefits? Deductible? Point of Service? We can help make sense of some common insurance terms that you may hear when navigating health insurance at the Student Health Center.
Unless otherwise listed, source for each term is: https://www.healthcare.gov/glossary/
The maximum amount a plan will pay for a covered health care service.
A request for your health insurer or plan to review a decision or a grievance again.
A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid also includes premiums.
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
Generally, plans with lower monthly premium have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.
Health care services that your health insurance or plan doesn't cover.
The insurance company’s written explanation regarding a claim, showing what they paid and what the patient must pay. The document is sometimes accompanied by a benefits check, but it’s more typical for the insurer to send payment directly to the healthcare provider.
The EOB is not a bill, although it will explain any charges that the patient still owes or may have already paid (in the form of a copay at the time the medical care was received, for example). If the patient owes additional money after the insurance company has paid its portion, the medical provider will send a separate bill, which should match the patient’s portion listed on the EOB.
Special note on privacy.
Please note that an EOB will be sent to the policyholder for your health insurance outlining all services rendered. If you do not want this individual to know why you came to the Student Health Center and what services you received, then you must tell a cashier to not bill your insurance. If you receive lab services that you do not want shared with the policyholder, then please inform the Lab Assistant. We won’t know this, so you must speak up and protect yourself. We will work with you to protect your privacy and to pay your bill.
(Source: www.healthinsurance.org/glossary/explanation-of-benefits/)
An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, insulin, and medical devices. You decide how much to put in an Flexible Spending Account (FSA), up to a limit set by your employer. You aren't taxed on this money. FSAs are sometimes also called Flexible Spending Arrangements.
A complaint that you communicate to your health insurer or plan.
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a monthly, quarterly, or yearly fee.
A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in a Health Savings Account (HSA) to pay for deductibles, copayments, coinsurance, and some other expenses, you may be able to lower your overall health care costs.
While you can use the funds in an HSA at any time to pay for qualified medical expenses, you may contribute to an HSA only if you have a High Deductible Health Plan (HDHP) — generally a health plan that only covers preventive services before the deductible.
Some health insurance companies offer HSAs for their HDHPs. Check with your company. You can also open an HSA through some banks and other financial institutions.
A plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower, but you pay more health care costs yourself before the insurance company starts to pay its share (your deductible). A high deductible plan (HDHP) can be combined with a health savings account (HSA), allowing you to pay for certain medical expenses with money free from federal taxes.
Admission to a hospital as a registered in-patient for medically necessary treatments; usually requires an overnight stay.
Care in a hospital that usually doesn’t require an overnight stay, such as diagnosis, observation, consultation, treatment, intervention, and rehabilitation services.
Some examples of some typical plan types:
Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Many states have expanded their Medicaid programs to cover all people below certain income levels.
Whether you qualify for Medicaid coverage depends partly on whether your state has expanded its program. Medicaid benefits, and program names, vary somewhat between states.
The Student Health Center contracts only with the State of Indiana Medicaid plans.
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
The facilities, providers, and suppliers your health insurer or plan uses to provide health care services.
Also known as out-of-network provider, this refers to a provider that doesn’t have a contract with your health insurer or plan to provide health services to you. You’ll pay more to see a non-preferred provider.
The most you would pay for a medical service before your insurance can cover the costs. This never includes your premium, balance-billed payments, and may not include copayments, coinsurance, deductibles, out-of-network charges, or other fees.
A benefit your employer, union, or other group sponsor provides to you to pay for your health care services.
A person or group in whose name an insurance policy is held.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Also known as prior authorization, prior approval, or precertification.
Also known as an in-network provider, this refers to a provider that has a contract with your health insurer or plan to provide services to you at a discounted cost.
The amount that must be paid to keep your health insurance or plan. You and/or your employer usually pay it monthly, quarterly, or yearly.
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of healthcare services for a patient.
Any medical healthcare professional – including a physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant – as allowed under state law, who provides, coordinates or helps a patient access a range of healthcare services.
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
