Components of Health Insurance
What is a premium?
The amount a member pay for your health insurance coverage, usually monthly.
What type of care focuses on preventing illness before it occurs?
Preventive care
Which type of plan generally emphasizes using a network of providers and may require a PCP to coordinate care?
HMO
What is in-network?
When a member receives care from a provider contracted with their health plan, the provider is considered this.
What is coinsurance?
The percentage of the cost you pay after meeting your deductible, when coinsurance applies.
What type of care is focused on treating an illness or condition that a patient already has?
Curative/Treatment care/Non-Preventive care
Which type of plan generally gives members more flexibility to see providers outside the network, although at a higher cost?
PPO
What is Tier 1?
In a tiered network, this tier generally has the lowest member cost.
What is a copay? Provide an example.
A fixed amount you pay for a covered service, such as $20 for a doctor visit.
What type of doctor do you usually see for regular checkups and common health concerns?
A primary care provider (PCP).
Which type of plan combines characteristics of an HMO and a PPO?
POS
True or False: Tier 3 automatically means the provider offers better quality care than Tier 1?
Why?
False, Tiers are mainly based on cost, not necessarily quality. A Tier 1 provider is generally more cost-effective for the member, but that does not mean they provide lower-quality care than a Tier 3 provider.
What is a deductible?
The amount you pay for covered services before the insurance starts sharing the cost for certain services.
What type of care helps a patient recover or regain function after an illness, injury, or surgery?
Rehabilitative care
What is a provider network?
A group of healthcare providers that have an agreement with an insurance plan to provide services to its members.
What is an out-of-network provider?
A doctor/provider who does not have a contract with their member's plan.
Does the deductible needs to be paid all at once?
No. It usually accumulates over time as you receive covered services that apply toward the deductible.
Why might a patient need more than one healthcare professional during their treatment?
Because different healthcare professionals have different areas of expertise and work together to meet the patient's needs.
A member says "I don't understand why my insurance works differently from my coworker's. We both have insurance from the same company."
Give THREE things you would want to verify before explaining the difference.
-Specific plan
-Provider/network status
-Benefits/coverage
-Cost-sharing
-Member eligibility
-Plan rules
Why is it usually important for a member to use an in-network provider?
Because the member may have lower out-of-pocket costs when choosing an In-Network provider