The “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health. However, if you do not understand the terminology you see on your paperwork, you might be missing out on a chance to audit your own medical bills.
Healthcare terminology can be complex, that’s why Robin Stockton , Director of the Center for Family Services, a community partner and special guest of Lourdes Health System, is here to explain the terminology and why it is an important part of your health advocacy.
Selected Podcast
Health Care Terminology 101
Featured Speaker:
Robin E. Stockton, M.Ed
Robin E. Stockton, M.Ed., is the Director of the Center for Family Services, a community partner and special guest of Lourdes Health System.Transcription:
Melanie Cole (Host): You get E.O.B.s in the mail you hear your deductible is not met. Health care terminology can be one of the most difficult things to understand, however to be your own best health advocate it is very important to understand what all the terms mean. My guest today is Robin Stockton the director for family services, a community partner and a special guest of Lourdes Health System. Welcome to the show Robin! So let's jump right in. We have a long list. Let's start with E.O.B. What is that?
Robin Stockton (Guest): Well thank you for having me. An E.O.B is an explanation of benefit and that is the form or document that may be sent to you by your insurance company. It can even come several months after you have had a health care service that was paid by the insurance company. You should get the E.O.B. if you have private health insurance, a health plan from your employer or Medicare. An E.O.B. gives you information about how an insurance claim from a health provider such as the doctor or hospital was paid on your behalf. Your E.O.B. has lots of useful information that may help you track down your health care expenditure and serves as a reminder of the medical services you received during the past several years.
Melanie: So people should not throw those out, that's a good way to kind of keep a good record of your own files.
Robin: Absolutely! We'll have all kinds of great information for you including the name of the person who received the services, the insured's I.D. number, the claim number, the provider name, the type of service, the date of service, the charge and the not covered amount as well as the total patient cost.
Melanie: So it's really a nice comprehensive explanation of all of the things that you had in that particular health care service. Now we also see their copay. What is a copay?
Robin: So a copayment is the fixed amount, like say $20 for example that you pay for a covered health care service after you've paid your deductible. So let's say your health insurance plan's allowable cost for a doctor's office visit is $100, your copayment for that doctor's visit would be $20.
Melanie: Ok, so copay is just something that you have to pay for any of these particular visits, with the exception of well visits, right? Usually some types of doctor's visits are exempt from copays.
Robin: Right, so it's really important to know that copayments or copays can vary for different services within the same plan. Like drugs, lab tests and visits to specialists. And you're right that some services are covered and for the consumer incur no copayment cost.
Melanie: Then what is coinsurance?
Robin: Coinsurance is the percentage of costs of the covered health care service you pay but use 20% for an example after you've paid your deductible. So let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%, if you've paid your deductible, you would pay 20% of $100 or $20. The insurance company pays the rest. If you haven't yet met your deductible you would be responsible to pay the full allowed amount or $100.
Melanie: Ok, so that you mentioned the word deductible a few times. People don't always know what that is either.
Robin: Absolutely! These terms are complicated to understand. That's why I so appreciate the opportunity to share some information about them with you. A deductible is the amount you pay for covered health care services before your insurance plan starts to pay. So if you have for example a $2000 deductible on your policy, you pay the first $2000 of covered services for yourself. After you pay your deductible, you usually only pay a copayment or coinsurance for covered services. Your insurance company pays the rest. It's important to know that many plans as we said before pay for certain services right up front like a check-up or disease management programs before you've met your deductible. So you should really check your plan details to see what's covered and what incurs a deductible.
Melanie: That's right! Because again some of those well visits do not even go toward your deductible.
Robin: That's correct! It's important to note that all market place health plans pay the full cost of certain preventative services, even before you meet those deductibles. And some plans have separate deductibles for certain services like prescription drugs.
Melanie: So then what is a premium?
Robin: A premium is the amount you pay for your health insurance every month. In addition to your premium you usually have to pay other costs for your health care as we mentioned before including a deductible, copayment and coinsurance. If you have a market place health care plan, you will pay a premium each month although you may be able to lower your cost with premium tax credit. It's really important when you're looking for a plan and choosing a plan and shopping for a plan to keep in mind that the plan with the lowest monthly premium may not be the best match for you. If you need much health care a plan with a slightly higher premium but a lower deductible may save you a lot of money. After you enroll or pick a plan you must pay your first premium directly to the insurance company in order to activate your coverage.
Melanie: So what is cost sharing?
Robin: Cost sharing is the amount of the cost covered by your insurance that you pay out of your own pocket. You truly share the cost with the company and cost sharing is the catch all phrase that generally includes deductible, coinsurance and copayment or similar charges. But it does not include premium, balance filling amount for non-network providers or the cost of non-covered services. If you are a member of Medicaid or CHIP, cost sharing would also include premium.
Melanie: So another thing people see on their E.O.B. Robin, is out of pocket expenses, and that is a big worry for a lot of people. How much am I going to have to pay out of pocket? What does that even mean?
Robin: So out of pocket costs are your expenses for medical care that are not reimbursed by insurance. Out of pocket costs again includes deductibles, coinsurance and copayments for covered services plus all cost for services that aren't covered. It's really important to understand what your out-of-pocket costs are as you're shopping for health care coverage.
Melanie: I think it's definitely one of the more important terms to note and then people hear and they worry if they're going to keep their job, if they're going to keep their insurance. What is cobra?
Robin: Cobra is actually a Federal law and what the law does is that it may allow a person who has lost job-based coverage to temporarily keep health coverage. After their employment ends they lose coverage as the dependent of the covered employee or they have another qualifying event. If a consumer elects cobra, which actually stands for Consolidated Omnibus Budget Reconciliation Act coverage. They pay 100% of the premium including the share that the employer used to pay plus the full administrative fee.
Melanie: Robin we hear all these terms and people are wondering what to do to get involved in the market place. And if they've missed the open enrollment, what is special enrollment and what does that mean? How do you get involved in that?
Robin: Absolutely! So a special enrollment period or a SEP is a time outside the yearly open enrollment period when a consumer can sign up for health care coverage. You qualify for a special enrollment period if you've had certain life events including losing health coverage, moving, getting married, having a baby or adopting a child. If you qualify for a special enrollment period you usually have up to 60 days following that event to enroll in a plan. If you miss that window, it's super important to know that you may have to wait until the next open enrollment period to apply. One important note, you can enroll on Medicaid and the Children's Health Insurance Plan or CHIP at any time of the year whether you qualify for a special enrollment period or not. Job-based plans, if you have one of those must provide a special enrollment period of at least 30 days.
Melanie: So if somebody does want to apply for CHIP or Medicaid, they can do that any time of the year? And is that in the same area? Do they go to the same kind of website to do that?
Robin: Yes, absolutely! So you're absolutely correct that you can enroll in Medicaid and in CHIP at any time of the year and you can enroll in Medicaid expansion states through health care.gov. And with the help of navigator at any point in any time during the year.
Melanie: So then, what is CHIP and why would somebody get involved in that is that for families? Are the adults not on that? What is that?
Robin: The CHIP is the Children's Health Insurance Plan and that is coverage for children up to the age of 18 for families who meet certain income guidelines.
Melanie: So the adults are not on a CHIP plan?
Robin: No.
Melanie: So you can give your children but the adults aren't necessarily covered there?
Robin: Right and one of the most wonderful features of the market place is that they can take a look at each individual member within the same tax filing family household and can discriminate between different eligibilities. So children in that family may qualify for the Children's Health Insurance Plan and parents may either qualify for either Medicaid or Market Place Plan depending on what their income levels are.
Melanie: So then wrap it up for us about what you want people to know about understanding the terminology to be their own best health advocate.
Robin: It's really complicated and there's a lot to learn and there are no silly questions about any of the terminology around health care insurance. It's really a critical piece that consumers educate themselves and understand some of these terms so that they can make the decisions that are best for their particular situation. There is help that is available out there through navigators and certified application counselors and www.healthcare.gov is a wonderful resource that has a wonderful glossary where all of these terms that I've talked about today are defined. So, if somebody is not understanding and they want just a quick resource to look up the definition of what something means they should absolutely get onto to www.healthcare.gov and take a look.
Melanie: Thank you so much Robin for being with us today! It's really great and such important information. You're listening to Lourdes Health Talk. And for more information you can go to www.Lourdesnet.org. That's www.lourdesnet.org. This is Melanie Cole, thanks so much for listening.
Melanie Cole (Host): You get E.O.B.s in the mail you hear your deductible is not met. Health care terminology can be one of the most difficult things to understand, however to be your own best health advocate it is very important to understand what all the terms mean. My guest today is Robin Stockton the director for family services, a community partner and a special guest of Lourdes Health System. Welcome to the show Robin! So let's jump right in. We have a long list. Let's start with E.O.B. What is that?
Robin Stockton (Guest): Well thank you for having me. An E.O.B is an explanation of benefit and that is the form or document that may be sent to you by your insurance company. It can even come several months after you have had a health care service that was paid by the insurance company. You should get the E.O.B. if you have private health insurance, a health plan from your employer or Medicare. An E.O.B. gives you information about how an insurance claim from a health provider such as the doctor or hospital was paid on your behalf. Your E.O.B. has lots of useful information that may help you track down your health care expenditure and serves as a reminder of the medical services you received during the past several years.
Melanie: So people should not throw those out, that's a good way to kind of keep a good record of your own files.
Robin: Absolutely! We'll have all kinds of great information for you including the name of the person who received the services, the insured's I.D. number, the claim number, the provider name, the type of service, the date of service, the charge and the not covered amount as well as the total patient cost.
Melanie: So it's really a nice comprehensive explanation of all of the things that you had in that particular health care service. Now we also see their copay. What is a copay?
Robin: So a copayment is the fixed amount, like say $20 for example that you pay for a covered health care service after you've paid your deductible. So let's say your health insurance plan's allowable cost for a doctor's office visit is $100, your copayment for that doctor's visit would be $20.
Melanie: Ok, so copay is just something that you have to pay for any of these particular visits, with the exception of well visits, right? Usually some types of doctor's visits are exempt from copays.
Robin: Right, so it's really important to know that copayments or copays can vary for different services within the same plan. Like drugs, lab tests and visits to specialists. And you're right that some services are covered and for the consumer incur no copayment cost.
Melanie: Then what is coinsurance?
Robin: Coinsurance is the percentage of costs of the covered health care service you pay but use 20% for an example after you've paid your deductible. So let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%, if you've paid your deductible, you would pay 20% of $100 or $20. The insurance company pays the rest. If you haven't yet met your deductible you would be responsible to pay the full allowed amount or $100.
Melanie: Ok, so that you mentioned the word deductible a few times. People don't always know what that is either.
Robin: Absolutely! These terms are complicated to understand. That's why I so appreciate the opportunity to share some information about them with you. A deductible is the amount you pay for covered health care services before your insurance plan starts to pay. So if you have for example a $2000 deductible on your policy, you pay the first $2000 of covered services for yourself. After you pay your deductible, you usually only pay a copayment or coinsurance for covered services. Your insurance company pays the rest. It's important to know that many plans as we said before pay for certain services right up front like a check-up or disease management programs before you've met your deductible. So you should really check your plan details to see what's covered and what incurs a deductible.
Melanie: That's right! Because again some of those well visits do not even go toward your deductible.
Robin: That's correct! It's important to note that all market place health plans pay the full cost of certain preventative services, even before you meet those deductibles. And some plans have separate deductibles for certain services like prescription drugs.
Melanie: So then what is a premium?
Robin: A premium is the amount you pay for your health insurance every month. In addition to your premium you usually have to pay other costs for your health care as we mentioned before including a deductible, copayment and coinsurance. If you have a market place health care plan, you will pay a premium each month although you may be able to lower your cost with premium tax credit. It's really important when you're looking for a plan and choosing a plan and shopping for a plan to keep in mind that the plan with the lowest monthly premium may not be the best match for you. If you need much health care a plan with a slightly higher premium but a lower deductible may save you a lot of money. After you enroll or pick a plan you must pay your first premium directly to the insurance company in order to activate your coverage.
Melanie: So what is cost sharing?
Robin: Cost sharing is the amount of the cost covered by your insurance that you pay out of your own pocket. You truly share the cost with the company and cost sharing is the catch all phrase that generally includes deductible, coinsurance and copayment or similar charges. But it does not include premium, balance filling amount for non-network providers or the cost of non-covered services. If you are a member of Medicaid or CHIP, cost sharing would also include premium.
Melanie: So another thing people see on their E.O.B. Robin, is out of pocket expenses, and that is a big worry for a lot of people. How much am I going to have to pay out of pocket? What does that even mean?
Robin: So out of pocket costs are your expenses for medical care that are not reimbursed by insurance. Out of pocket costs again includes deductibles, coinsurance and copayments for covered services plus all cost for services that aren't covered. It's really important to understand what your out-of-pocket costs are as you're shopping for health care coverage.
Melanie: I think it's definitely one of the more important terms to note and then people hear and they worry if they're going to keep their job, if they're going to keep their insurance. What is cobra?
Robin: Cobra is actually a Federal law and what the law does is that it may allow a person who has lost job-based coverage to temporarily keep health coverage. After their employment ends they lose coverage as the dependent of the covered employee or they have another qualifying event. If a consumer elects cobra, which actually stands for Consolidated Omnibus Budget Reconciliation Act coverage. They pay 100% of the premium including the share that the employer used to pay plus the full administrative fee.
Melanie: Robin we hear all these terms and people are wondering what to do to get involved in the market place. And if they've missed the open enrollment, what is special enrollment and what does that mean? How do you get involved in that?
Robin: Absolutely! So a special enrollment period or a SEP is a time outside the yearly open enrollment period when a consumer can sign up for health care coverage. You qualify for a special enrollment period if you've had certain life events including losing health coverage, moving, getting married, having a baby or adopting a child. If you qualify for a special enrollment period you usually have up to 60 days following that event to enroll in a plan. If you miss that window, it's super important to know that you may have to wait until the next open enrollment period to apply. One important note, you can enroll on Medicaid and the Children's Health Insurance Plan or CHIP at any time of the year whether you qualify for a special enrollment period or not. Job-based plans, if you have one of those must provide a special enrollment period of at least 30 days.
Melanie: So if somebody does want to apply for CHIP or Medicaid, they can do that any time of the year? And is that in the same area? Do they go to the same kind of website to do that?
Robin: Yes, absolutely! So you're absolutely correct that you can enroll in Medicaid and in CHIP at any time of the year and you can enroll in Medicaid expansion states through health care.gov. And with the help of navigator at any point in any time during the year.
Melanie: So then, what is CHIP and why would somebody get involved in that is that for families? Are the adults not on that? What is that?
Robin: The CHIP is the Children's Health Insurance Plan and that is coverage for children up to the age of 18 for families who meet certain income guidelines.
Melanie: So the adults are not on a CHIP plan?
Robin: No.
Melanie: So you can give your children but the adults aren't necessarily covered there?
Robin: Right and one of the most wonderful features of the market place is that they can take a look at each individual member within the same tax filing family household and can discriminate between different eligibilities. So children in that family may qualify for the Children's Health Insurance Plan and parents may either qualify for either Medicaid or Market Place Plan depending on what their income levels are.
Melanie: So then wrap it up for us about what you want people to know about understanding the terminology to be their own best health advocate.
Robin: It's really complicated and there's a lot to learn and there are no silly questions about any of the terminology around health care insurance. It's really a critical piece that consumers educate themselves and understand some of these terms so that they can make the decisions that are best for their particular situation. There is help that is available out there through navigators and certified application counselors and www.healthcare.gov is a wonderful resource that has a wonderful glossary where all of these terms that I've talked about today are defined. So, if somebody is not understanding and they want just a quick resource to look up the definition of what something means they should absolutely get onto to www.healthcare.gov and take a look.
Melanie: Thank you so much Robin for being with us today! It's really great and such important information. You're listening to Lourdes Health Talk. And for more information you can go to www.Lourdesnet.org. That's www.lourdesnet.org. This is Melanie Cole, thanks so much for listening.
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