Understanding your plan, any limitations, and what your out-of-pocket cost may be, is akin to learning a whole new vocabulary. Below a list of commonly used insurance terms and their definitions. When in doubt, call your provider’s Member Services number for clarification.
Insurance Premium: The monthly cost of your insurance plan, often shared between you and your employer.
Patient or member responsibility: Your share of the costs of the medical services received by the subscriber or dependents on the plan. The cost share and total member responsibility can differ based on whether your medical provider is in-network or out-of-network, so know the variations on your plan.
Deductible: A deductible is the amount you pay each year before your health plan begins to share in the cost of covered services. Typically, insurance will not cover anything until you have met your entire deductible.
Co-pay: A flat daily or per-visit rate you pay, common for in-network services. Your cost-share portion of the medical claim is the copay, and your insurance plan covers the entire remainder of the claim.
Co-insurance: A variable cost-sharing structure more common for out-of-network services. Your cost-share portion of the medical claim is an equivalent or smaller percentage of the medical claim, and your insurance plan covers the remaining percentage. For example, if your plan has a 20% co-insurance, you are responsible for 20% of the allowed amount of the claim and your plan covers the remaining 80%.
Out-of-pocket maximum: The out-of-pocket maximum is the maximum dollar amount you could possibly owe for covered medical expenses each year. Once you have met your out-of-pocket maximum, insurance will cover everything thereafter at 100%.
In-network benefits: Your insurance provider likely has a network of participating providers with contracted reimbursement rates. Services from in-network providers are typically covered with a lower out-of-pocket cost for members than services received from out-of-network providers.
Note: Patient responsibility payments for in-network services typically do not apply to out-of-network benefits and vice versa.
Out-of-network benefits: Some insurance plans allow members the choice of any doctor or medical service provider, regardless a whether that provider has a contract with the plan. These providers are considered out-of-network. However, the cost share and out-of-pocket maximum for choosing an out-of-network provider are usually higher than choosing an in-network provider.
Notification of Benefits (NOB): Your notification of benefits is a summary of your plan benefits, which is available to you from your insurance plan. It outlines your member responsibility and cost-share, out-of-pocket maximum, and plan limitations.
Pre-authorization: Pre-authorization is required for a variety of services covered by your insurance plan. When pre-auth is required, your plan will review the documentation of medical necessity of a service or procedure before agreeing to cover it. ABA Therapy almost always requires pre-authorization.