Health Care Reference Guide

A continuation of Health Care: Now and the Future

Reference Guide

With health care reform all over the news, most students have heard certain health care terms. However, some insurance terms might leave a few perplexed. Here are some of the health insurance vocab words and their definitions from www.healthinsurance.org, an online resource center for health insurance information:

Claim: This is when a person submits a request (or the health care professional, known as the provider) to a health insurance company in order to have the company pay for health care services.

Co-insurance: This is sometimes referred to as co-payment. This is the amount of money a person pays after the deductible has been met.

Co-payment: This is the amount of money a patient has to pay to the health care professional, and the health insurance pays for the rest.

Deductible: This is the amount of money a person must pay before the health insurance company will cover any of the health services. Usually this pay period is within a year.

In-network: Providers that the health insurance company has negotiated with in order to have reduced prices for the patient. This is generally cheaper than going out-of-network.

Out-of-network: These providers are not participating in reduced prices for a certain health insurance plan. Generally, none or little of the cost is covered by the health insurance company.

Pre-existing condition: A medical condition thought to be present before a person bought a health insurance plan is excluded from coverage. This can be anything from multiple sclerosis to depression. This is one way health insurance companies try to save money. Some plans offer coverage for the condition after a person has been on the plan for a period of time.

Provider: The health care professional, or doctor’s office, where a person gets his or her health care services.

Dr. Allan Markus from ASU explains three different health insurance plans:

Health Maintenance Organization (HMO): “An HMO is a plan where they have you see a primary care person…what they do is all your visits have to go through that first person,” Markus says. “It tends to be a cheaper plan.” Patients are generally not referred to a specialist unless the primary care physician cannot help them.

Preferred Provider Organization (PPO): “You can go anywhere you want, in their network or out of their network,” Markus says. “That allows the most freedom but it’s also the highest cost.”

Exclusive Provider Organization (EPO):“In the EPO…the insurance plan says you don’t need a referral to go to any doctors on the plan,” Markus says. This is similar to the HMO, since out-of-network health care professional services are not generally covered.  According to www.medhealthinsurance.com, EPOs can be cheaper than HMOs but are sometimes more restricted in regard to providers.