Health Insurance Key Definitions & Frequently Asked Questions Insert Name Here

Key Definitions Health Insurance Premium A contract between you and a health insurer that requires the health insurer to pay some or all of your healthcare costs in exchange for a premium Medicare, Medicaid, Blue Cross Blue Shield, United Healthcare, etc. Premium The amount that must be paid by you (the subscriber) for your health insurance plan

Key Definitions Contracted Rates Provider The amount that health insurance plans will pay to healthcare providers in their networks for covered services. These rates are negotiated and established in the contracts with the in-network providers Provider Healthcare professionals Physicians, Advanced Practice Providers (Nurse Practitioner, Physician Assistant) Healthcare facilities Hospital, Surgery Center, etc.

Key Definitions In-Network Out-of-Network The hospitals, providers, suppliers, and other healthcare facilities (for example, surgery centers) your health insurance plan has contracted with to provide healthcare services Out-of-Network The hospitals, providers, suppliers, and other healthcare facilities your health insurance plan has NOT contracted with to provider healthcare services Your payment responsibility will be different for in-network versus out-of-network

Key Definitions Explanation of Benefits (EOB) A statement sent by your health plan after you receive healthcare services from a provider. For each service it shows: Amount charged by the provider Plan’s allowable charge Plan’s payment The amount you owe It is NOT a bill – it is informational only

Key Definitions Explanation of Benefits (EOB) Amount Charged Charge is the dollar amount a healthcare provider sets for services rendered Allowable Charge / Allowed Amount The maximum amount the health insurance company will pay for covered services Also referred to as “eligible expense”, “payment allowance”, or “negotiated rate” Covered Services Medical services that are included in your health insurance plan Non-Covered Services Medical services that are NOT included in your health insurance plan

Key Definitions Explanation of Benefits (EOB) – Your Share of Payment Deductible The amount you are expected to pay for covered healthcare services before your health insurance plan begins to pay Example: If you have a $1,500.00 deductible – your health insurance will not pay anything until you have received covered healthcare services amounting to $1,500.00.

Key Definitions Explanation of Benefits (EOB) – Your Share of Payment Coinsurance Your percentage share for covered healthcare services after you have met your deductible Example: You have a 20% coinsurance. You receive healthcare services and your plan’s allowed amount for those services are $100.00. You will owe $20.00 for that service. Your health plan will owe $80.00. Copayment A fixed amount you pay for a covered healthcare service Different than coinsurance Does not count towards your deductible Common for Clinic Visits or ER visits

Key Definitions Explanation of Benefits (EOB) – Your Share of Payment Out-of-pocket healthcare costs Your expenses for healthcare services (deductible, coinsurance, copayments, and any “non-covered” services) Out-of-pocket maximum The limit on the total amount a health insurance plan requires a member to pay in a year Includes deductible, coinsurance, and copayments for covered services Once out-of-pocket is met for the year the health insurance plan will pay 100% of covered healthcare services Does not apply to non-covered healthcare services

Key Definitions Pre-Authorization A requirement that healthcare services must receive prior approval from the health insurance plan before being considered a covered service Also referred to as prior authorization If not pre-authorized, services will be considered non-covered Must complete pre-authorization BEFORE services are received Whose responsibility is it? ALL agreements are different – know your plan! Disclaimer: Prior authorization does not always guarantee payment

Key Definitions Inpatient Services “Admitted” to the Hospital with an order from your healthcare provider Provider must document the reasoning for admitting you as an Inpatient, also referred to as “medical necessity” Sometimes referred to as “Acute Care”

Key Definitions Outpatient Services Emergency Department Outpatient Surgery Lab, X-Ray, other imaging These services can also be done during an Inpatient Stay Observation Hospital outpatient service where the healthcare provider is determining whether your medical condition meets ‘medical necessity’ for Inpatient Services

Key Definitions Inpatient versus Outpatient Your health insurance plan will have different rules for inpatient versus outpatient services Payment Pre-authorization requirements Length of Stay requirements

Key Takeaways Know YOUR Plan!!! Know who is “in-network” Know what services are considered “covered” Know what services require prior-authorization Know what your deductible, coinsurance, and copayment responsibilities are If you don’t know – ASK!!

Key Takeaways Be Prepared If possible, ask for estimated charges for services you will be receiving Ask about payment arrangement options for out-of-pocket expenses Keep an open line of communication with the business office Patient Accounts, Patient Financial Services, etc.

Frequently Asked Questions Why do I get so many bills for the same service? There are multiple participants in some healthcare services Ambulance, Hospital, Physician, Radiologist, Pathologist, etc. There are various relationships with healthcare providers Some providers are employed by the organization where you receive healthcare services Some are independent, private practices

Frequently Asked Questions Why do I get so many bills for the same service? Facility Fees versus Professional Fees Facility Fees Hospital, Lab, X-Ray Bills are for service or procedure being provided Equipment, supplies, pharmaceuticals, hospital personnel (radiology technicians, lab technicians, nursing, etc.) Professional Fees Physician, Nurse Practitioner, Physician Assistant, Anesthesiologist, Pathologist, Radiologist

Thank You! Questions?

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