What are medical benefits and service terms? How do you know which one to choose? Here’s a medical-benefits-and-services glossary for health plans. Learn about terms like Coinsurance, Pre-authorization, and more. Once you know what the terms mean, you can apply for coverage.
Glossary of health plans
A medical benefits and service glossary of iehp.org, is a tool that helps people understand various healthcare terms. It outlines the health benefits, prescription benefits, costs, and limitations of each type of plan. It may also include network provider information. In some plans, you may receive specific coverage for specific medical services. The amount is sometimes referred to as the UCR (unit cost ratio).
A health plan’s drug formulary lists prescription medications covered under the plan. There are also exclusions and limitations which apply to specific situations or treatments. Typically, an explanation of benefits explains what your insurance company covers and how much you will need to pay. Another type of health insurance plan is group health insurance, a coverage plan offered by an employer for its employees under a single policy.
Examples of covered services
The types of services that are covered by health plans may vary. Some are covered for free, while others require a co-payment. It all depends on the plan you have and the deductible you have set. You should always check the details of your contract to see what is covered. You can also look at our Glossary to learn about health insurance coverage..
Coinsurance
What is coinsurance? Coinsurance is the amount you must pay when receiving health care services after you’ve met your deductible. Health insurance plans generally charge coinsurance as a percentage of the cost of medical services. You’ll have to pay a small amount upfront, usually between $25 and $100, for doctor’s visits, specialist consultations, and other covered services. In addition to coinsurance, some health insurance plans also charge copays, which are fixed amounts you’ll have to pay at the time of service.
You may be wondering, what is coinsurance? Simply put, coinsurance is the percentage of a bill you must pay. Most health insurance plans have coinsurance, along with deductibles and copays. Some of these cost-sharing features are the same. For example, a plan may have a $1,000 annual deductible and a 20% coinsurance. Likewise, a method may include a 50/50 coinsurance structure. In this scenario, the insurer pays 50% of the bill, and you’ll pay the other 50%.
Pre-authorization
The prior authorization of medical benefits and services of Health plans saves both payers and patients money. Using prior approval means that insurers do not pay for treatments that are not necessary or are not as expensive as generic versions. They also reduce the cost of prescriptions by ensuring that the medications are appropriate for the patient. Moreover, prior authorizations help the insurer to choose the most cost-effective drugs.
Although pre-authorization does not guarantee payment, it clearly indicates the health plan’s intention to pay for the services. However, this does not mean the insurance will cover 100% of the expenses. You may still have to pay co-payments and co-insurance on these services. Regardless of whether your health plan covers the benefits, contact your insurer and ask about pre-authorization before undergoing the treatment.
Network of providers
Having a Health plan covering a range of medical services is a good idea, but knowing your network is essential. Network adequacy refers to a health plan’s ability to provide all included services and reasonable access to providers within the network. Fortunately, many states have laws to ensure that programs maintain adequate provider networks.
Your health plan’s network consists of hospitals, medical professionals, and other health care facilities participating in the program. Depending on your health plan’s rules, these providers may be either in-network or out-of-network. For example, if your plan covers services at an out-of-network hospital, you will most likely pay more for them. This is because your health plan does not contract out-of-network health care providers, so they may not charge you as much as that in-network.
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