There is a lot to learn about health insurance, and these definitions may help you understand your health plan. Please understand that your benefits are established by your insurance company, not the medical facility.
Copayment is a fixed amount set by your health insurance paid to your providers. The copay is due at the time of service. Examples of copays:
- An emergency room copay might be $150.
- A physician office visit, $25.
- Prescription medication, $10.
Deductible is a fixed amount that you pay out of pocket each year before your health insurance begins to pay for medical services. If you have not met your annual deductible (expenses accured between January to December of the year), you are responsible for medical charges until it is reached. Sometimes the insurance company applies something towards the patient’s deductible and sometimes it does not.
Coinsurance is the amount that you pay for covered medical services after you’ve satisfied your deductible. Coinsurance is typically expressed as a percentage of the charge for a service rendered by a healthcare provider. For example, if your insurance company covers 80% of the allowable charge for a specific service, you may be required to cover the remaining 20% as coinsurance. The coinsurance will apply first then the Out of Pocket amount will apply after.
Maximum Out-Of-Pocket Costs. These are the annual limit for which patients are responsible under a health insurance plan. This limit does not apply to premiums, charges from out-of-network health care providers or services that are not covered by the plan. These charges happen when the deductible limit is met first and then the out-of-pocket limit is met. Once the annual limit is fully met by the patient’s plan, then the insurance will cover 100 percent of the allowed amount on the claim. This means no more copayments, deductible or coinsurance amounts to pay once the out-of-pocket annual limit is met.
Covered Services are what your plan will pay for completely or in part. Your health plan does not have to cover every service. The plan may only pay for a certain number of some services. Call the insurance company to see what services are covered. If a service you need is not covered, you should talk to your service coordinator before getting the service.
Prior Authorization means the emergency room does not need prior authorization. Some plans require prior authorization (or prior approval) before certain services are provided. The doctor provides information to the plan to request the authorization. If the plan does not authorize the service, the insurance company will not pay for the service.
In Network. Texas Senate Bill 425 ensures that a licensed emergency room does not need to be “in-network.” That is, part of your insurance company network.
Appealing: You cannot appeal if the service was not covered by the plan or if you received more than the amount of services allowed. If the insurance company still denies payment, you may be able to have an independent review organization (IRO) look at the denial. An IRO is an independent third party certified by the Texas Department of Insurance (TDI) (www.tdi.texas.gov/pubs/consumer/cb005.html).
Should you have any further questions or need clarification on your Frontline ER invoice, please contact us.
