Health Insurance FAQs

What is a “Provider Network”?
A network is a list of providers that will agree to accept your insurance plan. When you use providers “in the network”, the provider has agreed to accept a discounted fee that saves you money. There are various types of networks. The most common networks are the PPO “Preferred Provider Organization.”

What is a “Provider”?
A provider is your physician, hospital or other health care facility that provides your medical, dental or vision services.

What is “Preventative Care”?
Preventative Care services are to promote good health. Many plans offer “Preventative Care”. Some plans over “Preventative Care” once you have met you deductible, while other insurance carriers cover “Preventative Care” on a first dollar basis without needed to meet your deductible.

What is a Co-Pay?
A co-pay is a fixed dollar amount that your plan may require you to pay for specific medical services such as an office visit, or a prescription at the pharmacy, etc. Office visit co-pays aren’t equal, and vary based on the plan. With some plans, you pay the office visit co-pay for the cost of the office visit, while other services you may have done that day at the doctors office will apply to your deductible, where other plans office visit co-pay will also include services performed at the doctors office, i.e. office surgery etc. Upfront they are both office visit co-pays, however, the 2nd office co-pay could potentially offer much more benefit.

What is a “Deductible”?
A deductible is the amount of money you must spend each year before your policy begins covering expenses. Normally the deductible will start over each calendar year.

What is “Co-Insurance”?
Once you have met your plans deductible, the plan will start paying at a certain benefit level. The most common co-insurance level is 80/20, which means the insurance company will begin to pay 80% and you pay 20%. There are other co-insurance levels i.e. 70/30, 50/50.

What is a “Stop Loss”?
Once you have met your deductible, and your health insurance plan is now cost sharing your medical expenses, say 80%. If there was no stop-loss and the bill was $10,000 your 20% would equal $20,000. With the use of a stop-loss many plans would limit your 20%, 30% or even 50% to an amount that is acceptable to you such as $1,000, $2,000 etc, that is much better than $20,000.

What is “Maximum Out-of Pocket?
Maximum Out of Pocket is the amount of money that you will be required to pay per year for deductibles and co-insurance. When talking about Maximum out-of-pocket, you should take your “co-pays” into consideration.

What is a “Lifetime Maximum”?
Lifetime Maximum is the most amount of money the health insurance policy will pay for the entire life. The Lifetime maximum is usually based on each insured, while the most common Lifetime Maximums are between 3,000,000 and 8,000,000, though there are plans with much lower maximums between 50,000 and 250,000 that we wouldn’t recommend.

What are “Exclusions”?
The exclusions are medical services that the insurance policy will not cover. What the plan doesn’t cover is just as important of what the plan does cover. It is good to review the plans exclusions.

What are “Pre-existing Conditions”?
A pre-existing condition is a medical condition that an insured had before applying for the insurance policy. How pre-existing conditions are handled differ by insurance carrier and the state you live in. A pre-existing condition may be covered after a waiting period or some companies state if you explain your pre-existing condition on the health insurance application and you are approved for coverage, that pre-existing condition may be covered from the very first day of coverage.