Health Insurance Terms Explained Understanding Your Cove

Health Insurance Terms Explained: Understanding Your Coverage

December 03, 2020

Health Insurance Terms Explained: Understanding Your Coverage

The U.S. healthcare system is a complex network of doctors, developers, and health insurance companies. Countless stakeholders both feed into and draw from the system, making it difficult for any family or individual to navigate. New treatments and advances in technology can complicate the system even more. It’s hard to keep up. 

Fortunately, a health insurance broker can guide you through the underwriting process when it’s time for you or a loved one to get insurance. An agent can compare plans, find the lowest rates, and help you get a health insurance plan that meets your needs. They can also help you understand health insurance terms that may be confusing. 

Common Health Terms You Need to Know

Below are some common health insurance terms that you will hear once you get health insurance. If you have any further questions, feel free to contact Insurance Enterprise. We are here to help you get the right health insurance coverage for yourself, your family, or your business.

Allowed Amount – The highest amount the health insurance company pays for a medical service.

Benefit Period – Services covered under your plan. It also defines the time when benefit maximums, deductibles, and coinsurance limits build up. The coverage period is often one calendar year.

Coinsurance – A certain percent you must pay each benefit period after you have paid your deductible. This payment is for covered services only. You may still have to pay a copay.

Copayment – The amount you pay to a healthcare provider at the time you receive services. You may have to pay a copay for each covered visit to your doctor, depending on your plan. Not all plans have a copay. 

Deductible – The amount you pay for your healthcare services before your health insurer pays. Deductibles are based on your benefit period (typically a year at a time). 

Emergency Medical Condition – A medical problem with sudden and severe symptoms that must be treated quickly. In an emergency, a person with no medical training and average knowledge of health/medicine could reasonably expect the problem could:

  • Put a person’s health at serious risk.
  • Put an unborn child’s health at serious risk.
  • Result in serious damage to the person’s body and how his or her body works.
  • Result in serious damage to a person’s organ or any part of the person. 

Experimental or Investigational Drug, Device, Medical Treatment or Procedure – These are not approved by the U.S. Food and Drug Administration (FDA) or are not considered the standard of care.

HMO (Health Maintenance Organization) – Offers healthcare services only with specific HMO providers. Under an HMO plan, you might have to choose a primary care doctor. This doctor will be your main healthcare provider. The doctor will refer you to other HMO specialists when needed. Services from providers outside the HMO plan are hardly ever covered except for emergencies. 

HRA (Health Reimbursement Account) – An account that lets an employer set aside funds for healthcare costs. These funds go to reimburse covered services paid for by employees who take part. An HRA has tax benefits for employers and employees. 

HSA (Health Savings Account) – An account that lets you save for future medical costs. Money put in the account is not subject to federal income tax when deposited. Funds can build up and be used year to year. They are not required to be spent in a single year. HSAs must be paired with certain high-deductible health insurance plans (HDHP). 

Inpatient Services – Services received when you are admitted to a hospital. 

Long-term Insurance – A type of health insurance that covers certain services over a set amount of time (typically 12 months). 

Medically Necessary (or Medical Necessity) – Services, supplies, or prescription drugs needed to diagnose or treat a medical condition. Also, an insurer must decide if this care is:

  • Accepted as standard practice. It can’t be experimental or investigational. 
  • Not just for your convenience or the convenience of a provider
  • The right amount or level of service that can be given to you

Medicare – A federal program for people age 65 or older that pays for certain healthcare expenses.

Network Provider/In-network Provider – A healthcare provider who is part of a plan’s network.

Non-covered Charges – Charges for services and supplies that are not covered under the health plan. Examples of non-covered charges may include things like acupuncture, weight loss surgery, or marriage counseling. Consult your plan for more information.

Non-network Provider/Out-of-network Provider – A healthcare provider who is not part of a plan’s network. Costs associated with out-of-network providers may be higher or not covered by your plan. Consult your plan for more information.

Outpatient Services – Services that do not need an overnight stay in a hospital.   These services are often provided in a doctor’s office, hospital, or clinic. 

Out-of-pocket Cost – Cost you must pay. Out-of-pocket costs vary by plan, and each plan has a maximum out-of-pocket (MOOP) cost. Consult your plan for more information.

PPO (Preferred Provider Organization) – A type of insurance plan that offers more extensive coverage for the services of healthcare providers who are part of the plan’s network but still offers some coverage for providers who are not part of the plan’s network. PPO plans offer more flexibility than HMO plans, but premiums tend to be higher.

Premium – Payments you make to your insurance provider to keep your coverage. The payments are due at certain times. 

Provider (Healthcare Provider) – A hospital, facility, physician, or other licensed healthcare professional.

Short-term Insurance – A type of health insurance that covers certain services for a set period (6 months or less).

Urgent Care Provider – A provider of services for health problems that need medical help right away but are not emergency medical conditions.

Welcome to the MultiPlan PHCS Network

What are the benefits of PHCS coverage? You get to choose any doctor within the PPO network. This gives you an additional opportunity to save your healthcare dollars. MultiPlan’s PHCS Limited Benefit Network gives you discounted access to qualified doctors, healthcare facilities, labs, imaging centers, and hospitals at no additional charge.

Multiplan is one of the oldest and largest healthcare networks in the U.S. Currently, MultiPlan contracts with over 770,000 respected practitioners, 5,000 hospitals, and 70,000 ancillary care facilities, making it easier than ever to find a participating healthcare provider in your area. You save an average of 20-30% off inpatient and outpatient hospital charges when you use the MultiPlan Network.

We Offer Affordable Health Insurance in These States:

Contact Insurance Enterprise for Premier Health Insurance

If you have questions about group or individual health insurance and need health insurance quotes, contact Insurance Enterprise at 888-350-6605. Speak to a licensed agent and find out more about how you can get an affordable health insurance plan.