Health insurance jargon explained

If you're looking into health insurance - here are some terms you'll probably see explained by an actual human being:

Deductible

A deductible is how much the member pays for health care services out-of-pocket before health insurance kicks in. Once the deductible limit is met, the member may still need to pay copays and coinsurance until they’ve hit the out-of-pocket max, after which the plan pays for 100% of in-network services.

Individual vs. family deductibles

Each family member has an individual deductible. The family has a deductible, too. All individual deductibles funnel into the family deductible. The family deductible can be reached without any members on a family plan meeting their individual deductible. For example, a family of four on the 2021 Remove Saver Silver plan with Decent would have an Family Deductible of $8,500, while each individual member would have an Individual Deductible of $4,250. Once the sum of all deductibles combined reaches $8,500, the deductible will have been met.

Out-of-pocket Maximum

Out-of-pocket refers to the member’s personal cost. An out of pocket expense can refer to how much the co-payment, coinsurance, or deductible is. The out-of-pocket maximum is referring to how much the member would have to pay for the whole year out of their pocket, excluding premiums, after which the plan pays for 100% of in-network services.

Co-payment (Copay)

A fixed rate a member will pay for a health service. For example, the 2021 Zero Platinum plan on Decent has a Specialist Visit copay of $50. The amount spent on a copay does not apply to the deductible.

Coinsurance

This is the percentage an insurer will pay for a health service. The member pays the difference. For example, the Decent 2021 Remote Zero Bronze plan has a 50% coinsurance on specialty drugs after the pharmacy deductible is met. This means a member will pay for the cost of specialty drugs until they reach their Pharmacy deductible of $5,500. After that point, their plan will pay 50% of the cost of the specialty drug.

Contribution

This is the amount an employer pays toward employee health insurance premiums, which may or may not include a contribution to employee dependents’ premiums.

Claim

A claim is a request for payment sent to a health insurer, and is usually submitted by a health care provider for health services rendered to the member. How claims are paid depend on many factors. For example, the member’s plan, the provider’s network status, and any agreements in place with the provider and/or facility where the health services took place all play a role.

In-network

These are the physicians and medical establishments that deliver patient services covered under the insurance plan. In-network providers are the most affordable option to members. Insurers typically have negotiated lower rates with in-network providers.

Out-of-network

These are physicians and medical establishments that are not covered under your insurance plan. Services from out-of-network providers are usually more expensive than those rendered by in-network providers. This is because out-of-network providers have not negotiated lower rates with the insurer. The member’s plan may also dictate there is no coverage for out-of-network services outside of urgent and emergent care.

Referral

An official notice from a qualified physician to an insurer that recommends specialist treatment for a member. Referrals from a member’s Direct Primary Care physician are required for all non-emergency services on Decent plans.