Health insurance is a contract with a health insurance company (insurer) that requires the insurer to pay a portion of all health care costs in exchange for a set payment (premium). Insurance is beneficial in that it can offset expensive, unexpected health costs. To those unfamiliar with health insurance, understanding the insurance terminology can be intimidating. Not understanding these terms can make purchasing and managing health insurance quite tricky. Many people go without health insurance because they are not familiar with the words. To help, here are twenty Health insurance buzzwords you need to know.
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- Coinsurance. Coinsurance is the patient’s share of the health care service after the deductible is paid.
- Copay. Copay is a fixed amount of money needed to cover health services. A plan may require a set copay for services and prescriptions.
- Cost-efficiency. Cost efficiency refers to reducing the amount of unnecessary healthcare spending.
- Deductible. A deductible is the amount of money needed to pay out-of-pocket health care services before health insurance begins to help. Once the deductible is paid, the insurance will pay their portion.
- Essential Health Benefits. Essential Health Benefits are a set of health care services covered by plans in the Health Insurance Marketplace. Services include emergency services, hospitalization, maternity, and newborn care, mental health, prescription drugs, preventative and wellness services, and pediatric services.
- Evidence-Based Healthcare. Evidence-based healthcare refers to using scientifically based research to determine the best course of action for each patient.
- In-Network. Health care providers within the network are “network providers” or “in-network providers.” in-network refers to a group of doctors, hospitals, and other health care providers that a health insurance plan has partnered with to provide care to the plan’s members. Health insurance plans offer network provider information.
- Open Enrollment Period. An open enrollment period is when people can enroll in a health insurance plan for the following calendar year. Open enrollment for 2022 starts November 1, 2021, and ends January 15, 2022. Registration must occur by December 15 to begin coverage on January 1.
- Out-of-Network. Out-of-network includes doctors, hospitals, and other health care providers who have not partnered with the patient’s health insurance plan to provide care to the plan’s members. Out-of-network providers are subject to cost more.
- Out-of-Pocket. Out-of-pocket cost is the amount the patient pays for health care services. Out-of-pocket costs include a deductible, coinsurance, and copays.
- Out-of-Pocket Maximum. is the most the patient will pay in a policy period (typically a year) before the patient’s plan begins to pay 100% of the covered Essential Health Benefits. This limit includes deductibles, coinsurance, and co-payments. This limit does often exclude premiums.
- Patient Engagement. Patient engagement refers to a patient actively taking a role in their care. An engaged patient asks questions, utilizes educational resources, and makes sure that they clearly understand what their physician is communicating to them.
- Population Health. Population health refers to the collection of health outcomes of a group of people living together.
- Preventative Care. Preventative care refers to health care services focused on keeping a person healthy. Preventive care includes routine check-ups, patient counseling, screening tests, and immunizations. Plans are required to offer these services at no cost to the patient when provided by in-network doctors. The patient does not pay Co-payment and coinsurance for these services.
- Preventable Hospitalizations. Preventable hospitalizations refer to one in 10 avoidable hospitalizations. Hospitalizations are avoidable with outpatient treatment and disease management.
- Provider. A provider is a person or place a patient goes to receive health care services. Providers include doctors, hospitals, and pharmacies.
- Provider Network. A provider network is a group of doctors, hospitals, and other health care providers who have partnered with a health insurance plan to provide care to that plan’s members. A health insurance plan will state if it is in a provider network.
- Responsible Utilization. Responsible utilization refers to the quarter of healthcare spending that is unnecessary. Responsible utilization is a practice’s commitment to reducing unnecessary health care services and being as cost-effective as possible.
- Social Determinants of Health. Social determinants of health are factors other than health care that guide health outcomes, including zip code, employment status, and education. Social determinants of health are life/work conditions that influence health. Social determinants impact behavior development and influences health care.
- Value-Based Health Care. Value-based health care refers to care dependent on quality rather than quantity. Healthcare providers are incentivized based on quality rather than the number of services provided.
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It is vital to be familiar with and understand health insurance terms. An understanding of these terms can aid in cutting unnecessary costs or access benefits that were previously unknown. Be sure to share these terms with family and friends to have a better understanding of health insurance and its benefits.