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Glossary of Insurance Terms
Business and Family Plans
The amount you pay for covered health care services before your insurance plan starts to pay their portion of your medical bills. 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 co-insurance percentage for covered services. Your insurance company pays the rest. This cost-sharing arrangement only applies until you’ve met your out-of-pocket maximum.
For some plans, the deductible is waived for specific services, like generic prescriptions or doctor’s office visits.
Special Enrollment Period
A time outside the yearly Open Enrollment Period when you can sign up for health insurance. You may qualify for a Special Enrollment Period if you’ve had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.
If you qualify for a SEP, you usually have up to 60 days before or after the event to enroll in a plan. If you miss that window, you have to wait until the next Open Enrollment Period to apply.
Job-based plans must provide a special enrollment period of at least 30 days.
*You can apply for Medicaid and the Children’s Health Insurance Plan (CHIP) any time of year, whether you qualify for a Special Enrollment Period or not.
A health care provider is a person or company that provides a health care service to you. In other words, your health care provider takes care of you.
The health care provider you’re probably the most familiar with is your PCP or primary care physician.
The amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance.
When shopping for a plan, keep in mind that the plan with the lowest monthly premium may not be the best match for you. If you need a lot of health care, a plan with a higher premium but a lower deductible or out-of-pocket maximum may save you money.
If you are looking for a plan for yourself or your family, you may be eligible for a tax credit or subsidy through the federal marketplace. Tax credits subsidize part of your premium each month, so qualifying for a tax credit could lead to substantial savings. To find out if you are eligible please follow this link.
Out-of-pocket Maximum (OOPM)
The most you have to pay for covered services in a plan year. After you spend this amount on the combined total of deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.
The out-of-pocket limit doesn’t include your monthly premiums. It also doesn’t include anything you spend on services your plan doesn’t cover.
Open Enrollment Period
The yearly period when people can enroll in a health insurance plan.
For Individual/Family plans, open enrollment lasts from November 1st to December 15th. January 1st is the effective date for all applications received during open enrollment.
Open Enrollment periods for employer-sponsored plans vary by company.
The group of facilities [hospitals], providers [doctors], and suppliers that your health insurer or plan has contracted with to provide health care services. For example, SelectHealth has a network contract with all IHC-owned hospitals, while Regence Blue Cross Blue Shield typically does not.
Medicare is the federal health insurance program for:
Medicaid in the United States is a federal and state program that helps with medical costs for some people with limited income and resources. For more information on Medicaid, please follow this link.
The percentage of costs (30%, for example) of a covered health care service you will pay after you’ve paid your deductible.
Let’s say your health insurance plan’s allowed amount for a diagnostic test is $100 and your coinsurance is 30%.
If you’ve paid your deductible: You pay 30% of $100, or $30. The insurance company pays the rest.
If you haven’t met your deductible: You pay the full allowed amount, $100, and you receive a $100 credit towards meeting your deductible.
A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible.
Let’s say your health insurance plan’s allowable cost for a doctor’s office visit is $100. Your copayment for a doctor visit is $20.
If you’ve paid your deductible: You pay $20, usually at the time of the visit. The insurance company pays the rest.
If you haven’t met your deductible: You pay $100, the full allowed amount for the visit, and you receive a $100 credit towards meeting your deductible.
Copayments (sometimes called “copays”) can vary for different services within the same plan, like prescriptions, lab tests, and visits to specialists.
CHIP (Children’s Health Insurance Program)
Insurance program that provides low-cost health coverage for children aged 0-18 in families that earn too much money to qualify for Medicaid but not enough to buy private insurance.
Each state offers CHIP coverage and works closely with its state Medicaid program. You can apply any time and your coverage could begin at any time of year.
To learn more about CHIP please follow this link:
Life Insurance Plans
Term Life insurance is also known as pure life insurance. It is the type of life insurance that guarantees payment of a determined death benefit during a specified term or time period. You can select a term plan that will last 5 years, 10 years, 20 years, etc… Once the term expires, the policyholder can either renew it for another term, convert the policy to permanent coverage, as whole life, or allow the policy to terminate. The longer the specified term, the higher the premium will typically be.
Whole Life insurance is coverage that will last for a person’s entire life. It is also referred to as permanent or traditional life insurance. In addition to the death benefit, it can also build up a cash value that can earn interest and act as a savings account for the policyholder.
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