NDSU Extension Service - Ramsey County

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Health Insurance Lingo Continues

Health Insurance Lingo Continues

 

            Nonpreferred provider - A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a nonpreferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

            Out-of-network coinsurance - The percent (for example, 40 percent) you pay of the allowed amount for covered health-care services to providers who do not contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

            Out-of-network copayment - A fixed amount (for example $30) you pay for covered health-care services from providers who do not contract with your health insurance or plan. Out- of network copayments usually are more than in-network copayments.

            Out-of-pocket limit -How much you must pay for medical services during a policy period (usually a year) has a limit. Once that out-of pocket limit has been reached, your health insurance begins to pay 100 percent of the allowed amount for each service. This limit never includes your premium, balance-billed charges or health care your health plan doesn’t cover. Some health plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments or other expenses toward this limit.

            Pre-authorization - A decision by your health insurer or plan that a healthcare service, treatment plan, prescription drug or durable medical equipment is medically necessary.

            Preferred provider -A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who also are “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

            Premium - The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

            Prescription drug coverage -Health insurance or plan that helps pay for prescription drugs and medications.

            Provider -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.

            Primary care provider- 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 health-care services.

            Summary of benefits -Health Insurance companies must provide you with a short document detailing in plain language information about their health plan benefits and coverage. It will summarize the key features of the plan, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions.

            Tiers - Within a plan’s formulary list of medications covered, each medication will be placed in a tier, as in Tier 1, Tier 2, etc. Lower-level Tier 1 medications will be less expensive; higher-level tiers will cost you more.

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