The Affordable Care Act has created an opportunity for millions of people who were previously uninsured to receive health insurance at an affordable rate. Many of these people have never had insurance before, or had parents who received insurance through their job, and are not familiar with common insurance terms. While getting people enrolled is the main focus of navigators and community based organizations, understanding what you purchased and using it is another problem to tackle. Understanding your insurance plan will help your students save money. It will take time, and your students might need a cheat sheet when they look at their new insurance bill, but it is worth starting now as you are discussing health insurance.
Here are a few common insurance terms to start explaining. I got this from a packet created by the University of Maryland.
Essential Health Benefits
Your insurance must include items and services within at least the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventative and wellness services and chronic disease management; and pediatric services, including oral and vision care.
Preventative Services
Most health plans must cover a set of preventative services like annual check-ups, shots, and screening test at no out of pocket cost to you.
Network
The facilities, providers and suppliers your health insurer or plan has contracted to provide health care services.
Primary Care Provider
A Doctor, nurse practitioner, clinical nurse specialist or physician assistant who provides , coordinates or helps a patient access a range of health care services.
Specialist
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.
Urgent Care
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Premium
The amount that must be paid for your health insurance plan. Premiums may be shared between you and your employer.
Out-of-pocket costs
Your expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus costs for services that aren’t covered.
Deductible
The amount you owe for covered health services before your health insurance plan begins to pay.
Copayment
A fixed amount you pay for a covered health service, usually when you get the service.
Coinsurance
Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service.
HMO (Health Maintenance Organization)
A type of plan that usually limits coverage to care from doctors who work for or contract with the insurance company. It may require you to live or work in the insurance’s service area to be eligible for coverage. You may have to see your primary care provider before seeing a specialist.
PPO (Preferred Provider Organization)
A type of plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network, but you can use providers outside of the network for an additional cost.
POS (Point of Service)
A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plans network. They may also require you to get a referral from your primary care doctor in order to see a specialist.
