SAN ANTONIO – As if picking a plan wasn’t tough enough, you first have to decipher a long list of terms when it comes to health insurance coverage.
The KSAT Explains Team put together a glossary to make that tedious task a little easier.
“Understanding coverage — it’s something else,” said Anel Trevino, program navigator for the Bexar County Health Collaborative.
The collaborative is a nonprofit organization focused on helping people meet critical needs, including housing, health insurance, and more.
They have call-takers that will walk people step-by-step through their coverage options.
Trevino estimates the collaborative spends 50% of its time helping people understand terms within their insurance plan.
“Sometimes, not just the consumer is a bit confused,” she said.
The Health Collaborative also helps people navigate insurance claims when issues arise.
Premium
A premium is the cost you pay to have insurance coverage, usually per month.
It is not a payment for any doctor’s visits, procedures, or medications.
Copay
A copay is a fixed amount your insurance plan requires you to pay for a service covered by your insurance.
Those services are usually routine things that most people expect to encounter, such as seeing a doctor for a common illness (for example, the flu or a sinus infection).
Typically, your copay does not count toward your deductible.
Deductible
A deductible is an amount your insurance provider says you are responsible for paying before the insurance company pays its portion of your medical expenses.
You must pay your total deductible amount each year before your insurance plan pays anything. This applies to services that are not considered preventative or routine. (Remember, that’s where your copay comes in).
If you sprain your ankle and pay $500 for X-rays, that amount would count toward your deductible.
But if you have a $2,000 deductible and pay a $20 copay to see a doctor for a respiratory infection, you’ll still need to pay the $2,000 to hit your deductible.
Coinsurance
Coinsurance is similar to a copay, but instead of a fixed amount for routine or anticipated services, it is a percentage of the total cost that you are responsible for paying.
Here’s another example:
You see your doctor for that same respiratory infection. Turns out, your doctor examines you and can tell right away it’s a case of strep throat.
But if the doctor needs to test for the flu or COVID, the cost of the visit goes up, which means so will the percentage you pay with a coinsurance.
Out-of-pocket & out-of-pocket max
The term “out of pocket” refers to anything you are responsible for paying out of your own pocket.
A copay and deductible are two examples of out-of-pocket expenses.
An “out-of-pocket maximum” is the highest amount of your own money you will have to pay, usually per year, for medical expenses before your insurance covers the total cost.
“So once they hit the maximum out of pocket, then they’re done paying so long as they pay their monthly premium,” said Trevino.
A monthly premium for coverage does not count toward the out-of-pocket max.
What does count toward the max depends on a person’s individual coverage plan.
“Usually what can go into a maximum is going to be your medications, your visits to primary care physicians, to specialists, emergency visits,” Trevino said.
In network & Out of network
A physician who is in network is a doctor with whom your insurance company has a contract.
A physician or hospital that is out of network, meaning out of your insurance company’s network, does not have that working contract.
PPO
PPO stands for Preferred Provider Organization.
Under this type of insurance plan, a patient does not need a referral from a primary care physician to see a specialist.
PPO plans generally charge a consumer less to see a doctor who is in network and more to see a physician who is out of network.
HMO
Under a Health Maintenance Organization plan, or HMO, services are covered by insurance only if they are provided by in-network doctors or hospitals.
There are exceptions in case of an emergency.
An HMO plan also requires a referral from a primary care doctor to see a specialist.
EPO
An EPO, or Exclusive Provider Organization, only covers services provided by in-network doctors.
Similar to a PPO, patients under an EPO do not need a referral to see a specialist.
“Usually, your HMO are a little bit lower in price per month,” said Trevino. “But it’s important to keep in mind that if you’re going to see a specialist, you know you’re going to have to visit with that doctor. You’re going to have that expense. So sometimes, it’s best for the consumer to consider the PPO, or the EPO, so that they’re not spending that extra $20 visiting with the primary to get the referral.”
Health Savings Account
To make medical bills a little easier to handle, you can plan ahead with a Health Savings Account if your insurance plan offers that.
You can set money aside to put into your HSA to pay for certain health care costs, which can include your copay and deductible.
An HSA is usually only available if you have a high deductible plan.
If you don’t use that money within your coverage year, you can roll it over into the next year.
Flexible Spending Account
The Flexible Spending Account, or FSA, is opened through an employer if they offer it.
Money is this kind of account can also be used for certain medical expenses, but the funds do not roll over from year to year.
Both an HSA and FSA allow you to set aside money before taxes.
Medicaid
Medicaid is a joint state and federal insurance plan that is managed by individual states.
In Texas, people can get Medicaid coverage if they make below a certain income amount per year, depending on how many people are in their household.
For example, a family of four must make less than $59,400 a year to qualify.
Medicaid is for pregnant women, people caring for a child, people with a disability or people 65 and older.
Medicare
“Medicare is usually going to be for people who are 65 and above,” said Trevino.
Some people under 65 years old with disabilities also qualify for Medicare, which is an insurance program run by the federal government.
It all depends...
In the end, what’s covered by your insurance depends on the details of your individual plan.
What’s included and what’s covered differs from plan-to-plan and on the insurance companies that offer those plans.
“If you’re unsure, just give us a call, and we’ll walk with you step by step and help you,” said Trevino. “Anybody can get help.”
You can email the Bexar County Health Collaborative at info@healthcollaborative.net or call 210-481-2573. CLICK HERE TO FIND OUT MORE.