Insurance
Definitions
INSURANCE PREMIUM
This is a fixed amount that you pay to your insurance plan. Payments are generally made on a month to month basis. You pay this cost whether or not you receive medical care that month.
DEDUCTIBLE
This is the amount of money you pay for medical care before the insurance company starts to pay for care. You pay a pre-determined, fixed amount of money each time you receive medical care. Once you have paid that amount, or “meet your deductible”, your insurance company begins to cover some costs of your medical care. You can choose whether you have a high deductible or low deductible plan.
COPAYMENT
This is the fixed amount you pay for medical care services per visit after you have met your deductible. The health plan will pay the rest of the cost for the visit. For example, you may pay $30 for a physician visit at the time of the visit that would normally cost $150. The insurance company would be responsible for paying the remaining $120.
MINIMUM ESSENTIAL COVERAGE
The type of coverage needed to meet the health insurance requirement under the Affordable Care Act. This includes Marketplace coverage, job-based coverage, Medicare, Medicaid, TRICARE, the Children’s Health Insurance Plan (CHIP), and certain other insurance plans.
ESSENTIAL BENEFITS
These are the minimum requirements that all plans in the Marketplace must provide. Some plans may provide additional benefits.
Essential benefits include:
- Ambulatory patient services
- This is outpatient care, meaning care you get in the hospital without being admitted
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders, including behavioral health (counseling and psychotherapy)
- Rehabilitative and habilitative services and devices
- These are services and devices to help people who are injured, disabled, or who suffer from chronic conditions to recover mental and physical skills
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services
OUT-OF-POCKET MAXIMUM
- This is the highest amount you will have to pay out of pocket (deductibles, copayment, or co-insurance) for the year if you get sick. This amount does not include premium costs, balance-billing (the amount you have to pay after exceeding the Health Plan’s reimbursement for covered service), or health care services your insurance plan does not cover.
- Some insurance plans do not count out of pocket costs toward the out-of pocket maximum limit.
- In Medicaid and the Children’s Health Insurance Plan (CHIP) the limit does include the premium.
