The information provided in this section is as described on the website www.healthcare.gov, great resource to help you navigate the complex world of health insurance.
Health Insurance is defined as A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium.
Premium: 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, including a deductible, copayments, and coinsurance.
Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. After you pay your deductible, you usually pay only copayment or coinsurance for covered services. Your insurance company pays the rest.
Copayment: A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.
- If you've paid your deductible: You pay $;20, usually at the time of the visit.
- If you haven't met your deductible: You pay $100, the full allowable amount for the visit.
Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
Coinsurance: The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
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 pay 20% of $100, or $20. The insurance company pays the rest.
- If you haven't met your deductible: You pay the full allowed amount, $100.
Allowed Amount: The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”
If your provider charges more than the plan’s allowed amount, you may have to pay the difference. (See Balance Billing)
Balance Billing: When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Hammers and Riccio Imaging falls under this category.