Your Insurance Benefits Explained

New year, new clarity!  Let’s kick off 2024 by unraveling the mysteries of insurance coverage versus patient responsibility in healthcare. Navigating this landscape can be complex, but we’re here to break it down and empower you with knowledge for a healthier and more financially savvy year ahead. Read below as we explain what some of these insurance terms mean.

Deductible-The amount you owe for health care services your insurance plan covers before your plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services. The deductible may not apply to all services.

Embedded Deductible has two components, the individual for each family member and the family deductible.  When a family member meets their individual deductible, the plan will begin paying for that member per the plan’s coverage.  Once the family deductible is met, all family members will have expenses paid according to the plan even if an individual has not met their own individual deductible.

Non-Embedded Deductible means there is only one family deductible.  All family members’ out of pocket expenses count toward the family deductible and then they are all covered with the health plan’s usual co-pays or coinsurance.

Co-Pay-A fixed amount (for example, $25) you pay for a covered health care service, when you receive the service. The amount can vary by the type of covered health care service.

Co-Insurance-Your share of the costs of a covered health care service, typically after your deductible is met, calculated as a percentage (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance pays the rest of the allowed amount.

Out of Pocket-The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of your covered services. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesn’t cover.

Network-In-network are the facilities, providers and suppliers your health insurer has contracted with to provide health care services If out-of-network, there may be a different or separate deductible and /or co-insurance or co-pay.

*this summary is for informational purposes only, for more details and guidance, please consult with your insurance representative.