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Understanding your insurance coverage

Health insurance can be a complex topic. It’s important for you to understand your insurance coverage and have the best experience using Rula. This article will provide you with common insurance terms, and explains how to contact your insurance for accurate plan details.

Common terms explained

When it comes to health insurance, there are several key terms that you should be familiar with to better understand your coverage and potential out-of-pocket costs. Here's a summary of some of the most common insurance terms.

  • Copay: Fixed amount you pay for covered healthcare services at the time of service.

  • Coinsurance: Percentage of the cost of covered healthcare services you pay after meeting your deductible.

  • Deductible: Amount you must pay out of pocket for covered healthcare services before your insurance starts to pay.

  • Maximum Out-of-Pocket (MOOP) Limit: The maximum amount you'll have to pay for covered healthcare services in a plan year, including deductibles, coinsurance, and copayments.

Learn more about each term below:

 

Copay

A copay, short for "copayment," is a fixed amount you pay for covered healthcare services at the time of receiving them.

  • This amount is typically specified in your insurance policy and can vary depending on the type of service you receive (e.g., doctor's visit, specialist). 
  • Copays are usually different for different types of services and may also differ for other reasons such as place of service (e.g., in-office, telehealth).

 

Coinsurance

Coinsurance is a percentage of the cost of a covered healthcare service that you are required to pay after you've met your deductible.

  • Unlike a copay, which is a fixed amount, coinsurance is a proportionate share of the total cost of the service. 
  • For example:, if your coinsurance is 20% for a particular service and the total cost is $120, you would pay $24, and your insurance plan would cover the remaining $96.

 

Deductible

A deductible is the amount you must pay out of pocket for covered healthcare services before your insurance plan begins to pay.

  • For instance, if your deductible is $1,000, you'll need to pay the first $1,000 of covered expenses yourself before your insurance starts sharing the costs. 
  • After you meet your deductible, you may still have to pay copays or coinsurance, but your insurance will also start covering a portion of the costs.  
  • It’s also important to check whether your deductible applies to a particular service - many policies have a deductible, but it doesn’t always apply to all types of medical services.

It is also worth noting that some policies have both an individual and family deductible amount.  The family deductible is usually twice the amount of the individual deductible. 

  • If a patient has both an individual and family deductible, either or (not both) needs to be met before it’s considered satisfied.  
  • As an example, Joe has an individual deductible of $500 and a family deductible of $1,000.  He hasn’t yet met his $500 deductible, but his family deductible of $1,000 is met by other family members that have received medical care.  His deductible is considered satisfied.

 

Maximum Out-of-Pocket (MOOP) Limit

The maximum out-of-pocket (MOOP) limit is the most you'll have to pay for covered healthcare services in a plan year. This includes: deductibles, coinsurance, and copayments, but it excludes premiums and services that your plan doesn't cover.

  • Once you reach your MOOP limit, your insurance plan will typically cover 100% of the allowed amount for covered services for the rest of the plan year. 
  • It's important to note that MOOP limits can vary depending on your insurance plan and whether you're using in-network or out-of-network providers.

Similar to deductibles, plans may have both individual and family OOP max amounts. If a patient has both an individual and family OOP Max, either or (not both) needs to be met before it’s considered satisfied.  

  • As an example, Joe has an individual OOP Max of $2,500 and a family OOP Max of $5,000.  His family has not yet met the OOP Max of $5,000, but he has met his $2,500 OOP Max.  Joe will be covered 100% for future medical visits, but his family members may still have costs associated with their care.


Contacting your insurance for most accurate cost share and benefits

To ensure you fully understand your benefits and make the most of your coverage, it's best to contact your insurance provider or plan administrator directly for specifics. 

Your insurance carrier can:

  • Clarify Coverage: Insurance plans can be nuanced, and what's covered under one plan might not be covered under another. By contacting your insurance or plan administrator, you can gain clarity on the specific services and treatments covered by your plan.

  • Understanding Costs: Knowing your copays, coinsurance rates, deductible amounts, and maximum out-of-pocket limits can help you budget for healthcare expenses. Your insurance or plan administrator can provide detailed information on these costs, ensuring you're financially prepared for medical services.

  • In-Network Providers: Many insurance plans have networks of preferred healthcare providers. Visiting in-network providers often results in lower out-of-pocket costs. Providers do not always participate with every plan an insurance company offers - your insurance or plan administrator can furnish you with a list of in-network providers specific to your plan, helping you make informed decisions about where to seek care.

  • Preauthorization / Referral Requirements: Some medical treatments and procedures require a referral or preauthorization from your insurance company before they're covered. Your insurance or plan administrator can guide you through this process, ensuring you have the necessary approvals in place before receiving care.

Navigating healthcare benefits can feel like deciphering a complex puzzle. While contacting your insurance carrier is recommended for the most accurate benefits information - we at Rula also try to help our clients with running a Verification of Benefits (VOB) process. 

 

Best way to contact your insurance

There are typically several methods for contacting your insurance - including:

  • Check Your Insurance Card: Your insurance card typically includes contact information for customer service or member services. Use the phone number provided to reach out to your insurance company directly.

  • Online Member Portal: Many insurance providers offer online member portals where you can access detailed information about your benefits, claims, and coverage. Log in to your account or create one if you haven't already to explore available resources.

  • Email or Online Forms: Some insurance companies allow you to submit inquiries or requests for information through email or online forms on their website. Look for the "Contact Us" section on your insurer's website for these options.

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