Understanding Insurance Terminology:

1.Breaking down the Cost of Health Insurance: Deductibles, Premiums, Out-of-Pocket Max
“Understanding Your Health Insurance Costs,” Consumer Reports, accessed 03/22/2016

This is an overview of health insurance that will help clear things up and give you a better sense of how your money is spent. Helps you know what to look for when picking out a plan and how the plan uses premiums, deductibles, and out-of-pocket maximums should be interpreted for your personal health care needs. Stage 1 is about fulfilling your deductible requirement. Once you’ve reached that you’ll move to Stage 2 where now every time you use health coverage your insurance company will share part of the cost (Co-pay or Co-insurance) which is determined by the type of plan you pick. Once you’ve reached your out-of-pocket maximum for the year, your insurance company will pay the remainder of your coverage for the year at no cost to you.    The out-of-pocket max is the most money you will pay per year for coverage. After you’ve reached that, your health care services are free until your plan year starts over.  

2.What is Out-of-Pocket Maximum?
“Understanding Health Insurance: Out-of-Pocket Costs,” The Henry J. Kaiser Family Foundation, accessed 03-22-2016, http://kff.org/health-reform/

Stuff happens and having insurance helps a lot but it doesn’t mean all your health care is going to be free. There are lots of details about your insurance plan that affect how much you pay when you get sick or injured if you have Medicaid a lot of these services could very well be free otherwise you’ll likely have to pay something when you go to the doctor or fill a prescription. This is called a co-pay with a specific dollar amount like $25 provision or coinsurance which is a percentage of the bill. There’s also the deductible that’s how much comes out of your own pocket before your insurance starts paying. Depending on your plan you might have a deductible for all your care or might only apply to some types of care like hospital stays and prescriptions so read your plan materials well to avoid

3.How Premiums Work...
“Understanding Health Insurance: Premiums,” The Henry J. Kaiser Family Foundation, accessed 03-22-2016, http://kff.org/health-reform/

First things first you have to pay your premium every month to your insurance could get canceled, kind of like your cable subscription. You can also think of it as a shared healthcare piggy bank we all chip in each month even if we’re healthy so the money is there when we need it. If you get insurance at work your employer probably pays most of your premium and the rest comes out of your paycheck automatically. If you have Medicaid you most likely don’t have to pay any premium at all. The federal government in your state takes care of that. If you’re insured through a new health insurance marketplace depending on your income you may be eligible for a tax credit that pays a portion of your premium.

4.Understanding Provider Networks
“Understanding Health Insurance: Provider Networks,” The Henry J. Kaiser Family Foundation, accessed 03-22-2016, http://kff.org/health-reform/


Provider networks explain how doctors and hospitals are connected to your plan. Insurance companies negotiate discounts with some providers to stay ‘in-network’ (HMO) and this discount gets passed to you. But go out-of-network and you could end up paying the full costs using HMO plans.

Other plans like PPO’s your insurance will cover you no matter where you go even though you may pay a lot more if you go out-of-network. Sounds easy enough but sometimes staying in-network can be tricky in a hospital. It’s possible that your surgeon can be in-network while your anesthesiologist is not. If this happens to you don’t be afraid to negotiate with your provider or file an appeal with your insurer.