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Insurance Terms

The amount you pay monthly for your health insurance plan.

The amount you pay out of pocket before your insurance starts paying. For instance, I have a $2,000 deductible, so I’ll pay for most all my healthcare expenses until I’ve spent $2,000. At that point, insurance starts paying a portion of or all of my costs.

This is your insurance company’s approved list of doctors or providers. They’ve negotiated lower costs with these doctors, so if you use them, you’re considered “In-Network” and your costs are lower, too.

These are doctors or providers that aren’t on your insurance company’s approved list. If you choose one of these doctors, there are no negotiated prices, so you’ll pay more.

This is the most you’ll pay toward your healthcare in a given year. Let’s say you have an insurance plan with an out-of-pocket maximum of $5,000, once you’ve reached that amount, the insurance company picks up 100% of the covered costs for the rest of the plan year (excluding co-pays).

A small fee you pay each time you use a specific service – this fee doesn’t go toward meeting your deductible. For instance, some insurance plans have a $20 (or higher) co-pay for a doctor visit that isn’t preventive care (like an ear infection or the flu).

Some plans have you pay a portion of your expenses after the deductible is met. For instance, I might have a $2,000 deductible, so I’m paying 100% of the costs until I’ve spent $2,000. If my plan has 20% co-insurance, it means the insurance company picks up 80% of the costs, and I pay the other 20% (until I hit the out-of-pocket maximum amount)

Typically includes yearly check-ups, screenings (like a mammogram) and immunizations. As a result of Obamacare, preventive care is 100% paid for under most insurance plans and doesn’t require co-pays.

An EOB is a receipt that outlines your services and fees, what your insurance is paying for, what you are responsible to pay.

A health insurance plan with lower monthly premiums and higher deductibles than a traditional health plan. Your monthly premium for these plans can be up to 50% less than traditional insurance. This is typically better for people who are healthy or don’t use and don’t plan to use the healthcare system often. A CDHP allows you to get even more value by pairing it with an HSA or Health Savings Account.

With an HMO plan, you are required to use in-network providers. If you don’t, your visit won’t be paid for by insurance. In addition, you must have a referral from your primary doctor to see any type of specialist.

With a PPO plan, you have the option to use the list of In-Network providers. You can also use an “Out-of-Network” doctor, but your visit will cost more.

It stands for Consolidated Omnibus Budget Reconciliation Act, but it might be easier to think of it as a Continuation of Benefits plan. If you were covered under a company health plan and lost your coverage due to a “qualifying event” (like being laid off), this law allows you to pay to continue coverage at the company’s pricing for a set period of time.

As the name suggests, a Health Savings Account (HSA) allows you to set aside pre-tax money for healthcare expenses. This is only allowed if you have a Consumer Directed Healthcare Plan (CDHP). The funds contributed to your account are not subject to federal income tax at the time of deposit. For example, I can choose to take $100 each month and set it aside into an HSA – and because that $100 was taken before taxes were applied, it might have only reduced my pay check by $80. Now, I have $1,200 to spend during the year on my healthcare needs – I’ve saved money for health stuff BEFORE I need it AND I get a tax break! If you don’t use it, it rolls over into the next year. And, if your company is providing this and you leave the company, you get to take the funds in the account with you. Think of it like a 401K or IRA for your health.

This is very similar to an HSA, but only used by employers who fund the account and organize it for employees. The money is automatically deducted from your pay check each month on a pre-tax basis. There are 2 big differences: 1) you MUST use up the money in the account during the year or you’ll lose it, and 2) if you leave the company, you leave the funds in the FSA account.

This is an account your employer provides and funds with cash. When you have an allowable out-of-pocket medical expense, you can file a claim to have it paid for (or “reimbursed”). For example, my friend’s employer provides a $500 HRA. When she needed to have a doctor visit, she paid the doctor for the cost of the visit and then submitted her claim which was reimbursed. HRAs roll over from year to year, but if you leave the employer, you leave the funds in your HRA account.