Deductible, premium, co-pay? Health Insurance Keywords - #MedicalBillerExplains Ep. 1

Health insurance has a lot of complicated terms and concepts that even people who have been fully insured for their whole lives might not completely understand. We break down some of those terms so that you are better prepared.

Deductible, premium, co-pay? Health Insurance Keywords - #MedicalBillerExplains Ep. 1
Photo by Scott Graham / Unsplash


Frederick McNulty, Finestra: Health insurance has a lot of complicated terms and concepts that even people who have been fully insured for their whole lives might not completely understand. In this video, we're going to break down some of those terms so that you are better prepared. First, let's talk about health insurance. What exactly is health insurance and what does it do?

Amethyst Storey: Health insurance is what you can get to help cover you so that you don't have to pay the costs out-of-pocket upfront to a medical provider. What it does is it covers you to go see the doctor without having to pay up front until the claims are processed. For example, you buy a policy through Blue Cross Blue Shield. You go to the doctor, they ask you for your insurance and information. They take a copy of it, and then you will pay whatever your copay call insurance or deductible is, which we will get into later. And then the insurance company will cover the rest. You don't get a bill for that until after the claim is processed. So there's no need to bring cash to the doctor's office at all.

Finestra: You mentioned some, some sort of key phrases that we often hear. When you talk about health insurance, let's dive into some of those, what exactly is a deductible?

AS: So, a deductible is the amount of money that you agree to pay before your health insurance plan will pick up any of the costs. For example, you go to the emergency room, you have a broken leg. Deductible is $2,000. You'll pay the first $2,000 of that bill. And then you'll have what's called a co-insurance afterwards, which I will explain in a little bit. And the rest of the bill is covered by your insurance.

Finestra: What is a premium?

AS: The premium is the amount of money that you pay each month to keep your health insurance coverage. For example, my health insurance coverage is $55 a month. It's what you pay to have the coverage so that you don't have to pay out of pocket.

Finestra: So, it's kind of like your Netflix bill every month.

AS: Exactly.

Finestra: You mentioned co-insurance. What, what is co-insurance?

AS: So, a co what a co-insurance is it's a cost share. Some insurance plans will have both a deductible and a co-insurance. The co-insurance does not come into play until after you meet your deductible. For example, my policy has an 80 20 co-insurance, which means that the policy will pick up 80% of the allowed amount, which I also explain later, and I have to pay for 20% of the allowed amount. Co-insurance is just your part of the responsibility. And then your insurance picks up the rest.

Finestra: We often times hear a lot about copays. What is a copay?

AS: So, a copay is usually in lieu of a deduct or call insurance. A copay is a flat amount that you pay to your provider at each visit. And then your insurance covers the rest after you pay the copay.

Finestra: When people go in for any sort of medical care, uh, you know, it's very common to ask is, you know, is this out of network? Is this in network? What are of those two terms mean?

AS: So, in-network means that your provider has a contract with your insurance company and your specific plan out-of-network means that your provider does not have a contract with your insurance company. However, you may have outof network benefits, but oftentimes the outof network benefits come with a higher patient cost share, which means more money is going to come out of your pocket before the insurance will pay for the claims.

Finestra: Are you still able to go to a hospital or a doctor if it's out of network?

AS: So, you are able to go to a doctor or a hospital, if it's out of network, it works a little differently with hospitals. If you're getting emergency care, you're not obviously going to call your insurance company ahead of time and say, Hey, are you guys in network with my insurance company, an emergency room cannot charge you a higher rate. If they're out of network with your plan, if you're going in for emergency care, your co co-insurance or deductible would be the same as if the provider was in network.

It's a little different for doctors with doctors' offices. Patients are required to know their benefits ahead of time. So your best bet would be to call the insurance company, ask them for what your benefits are for the type of service you're going in for. And if you give them your doctor's information, they can tell you if they're an in network or an out of network provider, I would opt for in network because your cost share is going to be a lot less. If you see an in-network provider. And in some cases like for preventative care, which are things like your annual physical or any kind of preventative vaccines, there may not be a cost share at all. If you go see an in-network.

Finestra: I think a lot of people feel more of a connection to their primary care physician, their local doctor, than they do to their insurance company. Are they able to call their doctor to find out information about how much they'll be paying?

AS: So, some doctors' offices will call and verify benefits for you. I know as a biller for every provider I work with, I call and I verify the code specific and place of service, specific benefits for accuracy, just because I have access to the doctors tax ID and MPI information that will allow me a little bit more accuracy insurance companies. When they talk to patients, they're very different than when they talk to billers. As a biller, I'm able to squeeze the information out of them that the provider and the patient needs

Finestra: When patients are, are going on to their first insurance plan or, or maybe switching insurances, there's this, this phrase comes up a lot open enrollment. What is open enrollment?

AS: So, open enrollment is a set couple of weeks during the year where people are either able to obtain new insurance change their current insurance plan or cancel their insurance altogether. Usually those things have to be done within that set open enrollment time. There are a few exceptions. If you lose insurance coverage during a time, that's not open enrollment. If you have a baby, if you adopt a child, if you get married, those are some circumstances where you would be able to do enrollment at that time during the year, even if it's outside of open enrollment.

Finestra: When would you not be able to sort of get onto a new plan?

AS: So, if you're trying to get onto a new plan outside of open enrollment and you don't fall into one of those categories that I mentioned, they're not going to allow it and you'd have to wait for the next open enrollment. Or if you met one of those specific criteria

Finestra: We've discussed co-insurance and copays, uh, are they related at all? I think people can get these two things confused because of the word co.

AS: So, usually with plans that have a co-payment, your premiums are going to be a little higher because you only have one set payment that you have to make for each visit with a provider plans that have a deductible on coinsurance. And for the most part, the two go together. If you have a deductible, you generally have a coinsurance after that deductible is met, your premiums are going to be a lot lower with those plans, but you're going to end up paying more on the other side of things.