The Affordable Care Act has introduced a whole marketplace for Americans seeking health insurance. But navigating the array of offerings can be tricky. Deciphering insurance terminology is key to understanding your options, and you may need an expert to guide you toward the plan that works best for you and your family.
Enter BridgeSpan Health: a friendly company that can help you navigate the marketplace by offering personalized health insurance that fits your lifestyle and budget. With simple, convenient online tools, BridgeSpan gives individuals and families more control when choosing their health care.
You should feel informed and empowered throughout your search for the best plan. This helpful glossary of important terms pertaining to the Affordable Care Act — brought to you courtesy of BridgeSpan — can help you make an education decision about the health coverage that suits you best.
The Basic Terms
Claim: An official request to your insurance submitted by you or your health care provider for reimbursement.
Coinsurance: After you’ve met your health plan’s deductible, you and your insurance company pay a certain percentage of the cost of a service (eg. they pay 90%, you pay 10%).
Co-pay: A flat fee you pay out-of-pocket for a covered service.
Deductible: What you’ll spend on health services before your insurance plan’s coverage kicks in.
Formulary: This is just a fancy word for “drug list.” It’s all the prescription drugs — generic or brand-name — that are covered by your insurance. If a drug doesn’t appear on the list, it’s considered “non-formulary,” and is probably more expensive.
FSA: (Flexible Spending Account): Tax-free money set aside (usually from your paycheck) to over medical expenses.
HSA: (Health Savings Account): Like an FSA, but with funds that will roll over into the next year.
In-network: Doctors or providers whose services are covered by your insurance. This is synonymous with “covered” providers.
Open enrollment period: The set time (usually in the fall) when you can enroll in or update your health insurance.
Out-of-network: Doctors or providers who do not participate in your insurance plan.
Out-of-pocket expense: Any expense not covered by your health insurance. It’s total amount owed minus the amount your insurance plan pays.
Out-of-pocket maximum: Once you’ve spent this amount on health care costs, any further expenses will be covered by your insurance for the rest of the year.
Premium: What you pay each month for your health insurance.
Primary care physician: A physician — either an M.D. (Medical Doctor) or a D.O. (Doctor of Osteopathy) — who offers or coordinates a variety of health services, like your annual physical.
Provider: Any physician (M.D. or D.O.), health care professional, or health care facility licensed, certified or accredited as required by state law.
Specialist: A doctor that focuses on just one type of medicine, for instance, psychiatrists, cardiologists, orthopedists, and more.
AHN (Accountable Health Network): A group of providers who collaborate on your care.
Coordination of benefits: If you’ve got multiple health insurance plans, the companies will work together on medical claims to make sure you receive the full benefits. That way, you can reduce costs.
Pool: Insurance companies gather the premiums of individual subscribers into one fund, known as a pool, which is then used to pay for the health care of the members within that pool.
Preventive care: Any care that is preventive against disease, including physicals, immunizations, cancer screenings, and more.
Tax credit: Tax credits for insurance are calculated based on income — there is a set maximum amount a low-income family will pay for insurance.
Tax penalty: If for some reason you fail to acquire health coverage, under the ACA you could face tax penalties.
What You Get with Each Benefit
Ambulatory care: Any service a patient receives without being admitted to a hospital, including outpatient surgery and hospice care. This is also known as outpatient care.
Chronic disease management: For those with chronic illness, this service includes monitoring, screenings, check-ups, and education.
Laboratory services: Tests a doctor orders to determine a diagnosis, such as blood tests, imaging services, screenings, and more. Some preventive measures, like breast cancer screenings, are totally covered.
Maternity and newborn care: Care for women going through labor, delivery, and post-delivery. It also includes care for newborns.
Mental health benefits: Impatient and outpatient care that evaluates and treats a mental health or substance abuse disorder.
Prescriptions: Medication to treat an illness or condition as prescribed by your physician, such as antibiotics for a bacterial infection or insulin for diabetes.
Ready to arm yourself with the best care you can get? Then take the time to peruse the other resources on the BridgeSpan Health website, and empower yourself to make the right choice.
BridgeSpan’s insurance plans are entirely web-based. Members can manage every aspect of their health care — claims, benefits, prescription drug lists, payment options, and forms — online. And if you’re still in the process of choosing the best plan for you, check out BridgeSpan’s new member checklist, and peruse the top ten questions for those looking for coverage. You can also find helpful information on the top ten essential health benefits required by the Affordable Care Act.
Knowledge is power, so get out there and get covered, you health insurance wiz! Now there’s nothing standing in your way as you shop for the plan that best suits your individual healthcare needs. Open enrollment begins November 1, 2015 and ends January 31, 2016. Don’t miss the deadline!
Jessica Ferri is a writer based in Brooklyn. You can find her at jessicaferri.com.