Call toll free 800.822.4629
Health Insurance Ohio, think well live well

Insurance Terms


Copay:

This is the cash you pay at the time of service. Your copay may or may not be your total charge for the service. Your copays are in addition to your plan deductible and Maximum out of pocket.


Dr. Copay:

Usually $25, $30 or $35 depending on the plan you choose. Once you pay your copay, the remainder of your charges for that visit is paid at 100%. Lab work and x-ray done in your doctor office are not included in your copay.


E/R Copay:

Some plans have an E/R copay in addition to your deductible and coinsurance.


Facility Copay:

This is rare but some plans have facility copay in addition to your deductible and coinsurance.


Prescription Copay:

Most prescription cards are copay driven. You have different copay for generic, preferred brand and non preferred brand drugs.


Co-Insurance:

This is the percentage of your bill you are responsible for after you have met your deductible and before you have reached your Maximum out of Pocket. 80/20 Co-insurance is the most common co-insurance. Many companies offer 70-30 or 60/40 coinsurance to lower your premium. The most important part of coinsurance is the STOP GAP. This is the amount you pay before you reach your maximum out of pocket. You need to know your stop gap. It is not equal with all companies. 80/20 to $10,000 is $2000 stop gap. 80/20 to $15000 has a stop gap of $3000. What is the Stop Gap of the plan you choose?


Maximum Out of Pocket:

This is the total of your deductible and coinsurance that you must meet before the company pays 100% of your bills. Your deductible $500 plus coinsurance $2000 equals your annual maximum out of pocket of $2500. Your Maximum Out of Pocket may be more important than your deductible. A $2500 deductible 100% plan (no coinsurance) has a Maximum out of pocket of $2500 dollars. This is the same as the $500 deductible 80/20 to $10,000. Your premium is much lower with the $2500 deductible 100% plan and your Maximum Out of Pocket (exposure) is the same.


Underwriting:

All companies look at your age, height/weight, tobacco use, history of medical conditions, current medical conditions and medications to determine if you are eligible for coverage, if your premium needs to be rated up to cover conditions. Some companies rate up for health conditions and medications. Some companies issue exclusion riders (won’t cover the condition) Depending on the company you apply with, your condition can be 1) rated up 2) ridered out or 3) you can be denied coverage due to medical conditions.


How can you choose a health plan if you have health conditions and the quoting tool you used did not ask about your height /weight or health conditions? How can you expect to know which companies will cover your conditions and which will not?


I want to become your trusted health insurance adviser and help you choose the plan and level of coverage that best meets your needs.

TERMS YOU NEED TO BE FAMILIAR WITH


 

Request a Quote