Jeez, health insurance coverage is a complicated business. However, knowing a few key terms can go a long way to making it more understandable. Take a look at the following terms. With these in your arsenal, you’ll confidently navigate your way through insurance documents.
The amount the policy-holder or their sponsor (such as an employer) pays for a health plan.
The amount the insured (that’s you!) must pay out-of-pocket before the health insurer pays its share. For example, policy-holders might have to pay a $500 deductible per year before any of their health care is covered by the health insurer. It may take several doctor’s visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care. Some plans may have separate deductibles for specific services.
The amount the insured person (you, again!) must pay out-of-pocket before the health insurer pays for DME. For example, an insured person might pay a 20% co-payment for an orthotic device.
Exclusions are services that are NOT covered. Insured are generally expected to pay the full cost of non-covered services out of their own pockets. Please note that foot orthotics are often excluded unless the patient has a diabetes diagnosis.
Some health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan’s maximum payment for a specific service. In addition, some insurance company plans have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when the benefit maximum is reached and the policy-holder must pay all remaining costs.
The insured person’s payment obligation ends when they reach the out-of-pocket maximum, after which the health insurance pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category or can apply to all coverage provided during a specific benefit year.
In-network refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider.
A certification or authorization an insurer provides prior to medical service stating it will cover a percentage of the cost. This is often required for DME.
Explanation of Benefits
A document by an insurance company to a patient and the provider of service explaining what part of the medical service was covered.
A written order from your primary care doctor or specialist that is always required by our office. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.