Health insurance can be confusing

Health insurance can be confusing, with lots of unfamiliar terms and acronyms. Understanding the basics of health insurance can help you choose the right plan for you and your family. Here are some common health insurance terms you need to know:

• Premium: The amount you pay each month to maintain your health insurance coverage.
• Deductible: The amount you have to pay out of pocket before your insurance coverage begins to kick in. For example, if your deductible is $1,000, you will have to pay the first $1,000 of your medical expenses before your insurance starts paying.
• Co-pay: The fixed amount you pay for a covered service, such as a doctor’s visit or prescription drug, after you have met your deductible.
• Coinsurance: The percentage of the cost of a covered service that you are responsible for paying after you have met your deductible. For example, if your coinsurance is 20%, you would be responsible for paying 20% of the cost of a covered service, and your insurance would pay the remaining 80%.
• Out-of-pocket maximum: The maximum amount you will have to pay for covered services in a given year, including your deductible, co-pays, and coinsurance. Once you reach your out-of-pocket maximum, your insurance will cover the rest of your covered expenses for the year.

In-network providers

• Network: The group of healthcare providers and facilities that have contracted with your insurance company to provide services to their members. In-network providers typically have lower costs than out-of-network providers.
• Provider: Any healthcare professional or facility that provides medical services, such as doctors, hospitals, and clinics.
• Pre-authorization: The process of obtaining approval from your insurance company before receiving certain medical services or procedures. Your insurance company may require pre-authorization for services that are expensive or not typically covered.
• Exclusions: Services or conditions that are not covered by your insurance plan. It is important to understand what is not covered by your plan so you can plan accordingly.

Open enrollment: The period of time when you can enroll in or change your health insurance plan. Open enrollment typically happens once a year and is a good time to review your coverage and make any necessary changes.

Pre-existing condition refers to any medical condition that existed before you enrolled in your current health insurance plan. Examples of pre-existing conditions include diabetes, asthma, cancer, or heart disease.

Before the Affordable Care Act (ACA) was enacted in 2010, insurance companies could deny coverage or charge higher premiums to individuals with pre-existing conditions. However, under the ACA, insurance companies are required to cover individuals with pre-existing conditions and cannot charge them higher premiums.

Additionally, under the ACA, individuals cannot be denied coverage or charged more based on their health status. This provision is known as the “guaranteed issue” and “community rating” rules.

It’s important to note that not all health insurance plans cover pre-existing conditions in the same way. Some plans may have waiting periods before covering pre-existing conditions, while others may have exclusions for certain conditions. Be sure to read your policy carefully and understand how pre-existing conditions are covered under your plan.

Pre-authorization