Do you ever wonder about all the technical terms and jargon health insurance companies use to explain the fees you need to pay? There are so many ways to say “you need to pay,” but what does each one mean and how are they different?
If you’re using insurance to pay for acupuncture, you’ve definitely heard these terms before. If you’re using insurance to pay for acupuncture and you’re a Dylan Stein Acupuncture patient, we’ve probably already talked about these terms. Regardless, it’s always good to review.
If there’s a term that you come across that I don’t talk about here, please leave a comment and I’ll reply.
Health insurance payment terms:
- Benefits – Most simply, what your insurance covers and what your it doesn’t cover. Having acupuncture benefits means your plan covers acupuncture.
- Rider – A rider is an add-on to your insurance plan that extends your benefits. Acupuncture is added to an insurance plan through an additional rider.
- Claim – A request for payment for a medical service, like an acupuncture treatment. Either a plan member (a patient) or a provider can file a claim.
- In-network provider – A healthcare provider, hospital, lab or pharmacy that has become a preferred provider by an insurance company. In-network providers have accepted negotiated payment rates from the insurance company so patients pay less. Dylan Stein Acupuncture is an in-network provider with Empire Blue Cross/Blue Shield.
- Out-of-network provider – A healthcare provider, hospital, lab or pharmacy that is no part of an insurance plan’s preferred provider network. Usually, you pay more to see an out-of-network provider. Dylan Stein Acupuncture is an out-of-network provider with Aetna, Cigna, and Oxford/United Healthcare. However, there is good news! Those plans don’t have in-network acupuncturists, so you’ll still be covered without having to pay excessive fees.
- Co-payment (Co-pay) – A co-pay is a fixed dollar amount set by the insurance that a person has to pay at the time of an appointment (for a medical service). Co-pay amounts may vary depending on the kind of appointment (sick visit versus annual check-up) or the type of provider you’re seeing (primary care doctor versus specialist).
- Co-insurance – Co-insurance is a percentage amount determined by the insurance company that a person needs to pay after the annual deductible is met. Your co-insurance will vary depending on what kind of appointment and what kind of doctor. The percentage fee for co-insurance is based on what the insurance will allow a healthcare provider to charge for a medical service.
- Annual Deductible – Your deductible is a fixed dollar amount that you need to pay before your insurance starts to cover your healthcare costs. Deductibles are for a set period of time, typically per year, so the deductible resets at the end of the period. Some plans have no deductible. The amount of a deductible will vary from plan to plan.
- Out-of-pocket maximum – The maximum amount you’re expected to pay out-of-pocket. Once this amount is paid, your insurance covers all expenses.
- Premium – The monthly fee you pay to participate in your insurance plan.
- Healthcare Savings Account/Flexible Spending Account (HSA/FSA) – An HSA or an FSA is a way for you to put aside money before taxes that you can later use to cover your medical expenses. Acupuncture is an eligible expense, so you can use your HSA/FSA to pay for acupuncture if your insurance plan doesn’t have acupuncture benefits. If your plan does cover acupuncture, you can use your HSA/FSA to pay for your co-pay and co-insurance.
- PPO Insurance Plan – PPO stands for preferred provider organization. You can pick which healthcare providers you want to see, but preferred providers incur a lower fee.
- EPO Insurance Plan – EPO stands for exclusive provider organization. This is a more restricted type of PPO in which only coverage of network providers, except in the case of an emergency.
- HMO Insurance Plan – HMO stands for health maintenance organization. HMOs provide payment for and do the actual healthcare visits. There are strict limitations on networks of doctors and who a person can see for healthcare.
- POS Insurance Plan – POS stands for point-of-service. POS plans are a hybrid of PPO and HMO plans. In-network providers are treated like they would be in HMO plans, but out-of-network providers may be seen as in a PPO.
- Medicare Supplemental Plan – Supplemental health insurance plans to cover the cost of healthcare services not covered by Medicare.