1. Health Insurance Key Definitions & Frequently Asked Questions
Insert Name Here

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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, deductible – your health insurance will not pay anything until you have received covered healthcare services amounting to $1,

8. 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 $ 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

9. 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

10. 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

11. 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”

12. 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

13. 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

14. 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!!

15. 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.

16. 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

17. 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

18. Thank You!
Questions?

19. Insert Contact Information Here