An overview of 12 common U.S. health insurance terms that could mean money out of our pocket.

1. 12 U.S. HEALTH INSURANCE
TERMS YOU NEED TO KNOW
That Cost You Money

2. Major Disclaimer
I am not an attorney –
nor do I play one on TV
The following guide does
not constitute legal
advice.

3. Does your health insurance
Confuse you?
Bore you?
All of the above?

4. All you want to know is
how much will
it cost –
right?

5. about 12 health
insurance terms

6. about 12 health
insurance terms
and how they cost
you money

7. Keeping it simple: 3 categories
Money Provider Plan
Terms Terms Terms

8. MONEY
TERMS

9. #1 – PREMIUM
THE PURCHASE
PRICE FOR HEALTH
INSURANCE
The higher the level of coverage –
the higher the premium

10. Do you have health insurance
through your
employer?

11. Do you have health insurance
through your
employer?
Or do you purchase
your own?

12. If you purchase your own
Sorry you pay the entire
premium cost
At least for now

13. If your employer offers coverage
look for health insurance term #2

14. #2 – CONTRIBUTIONS/COST-SHARING
THE AMOUNT YOUR EMPLOYER
CONTRIBUTES TO THE COST
OF THE PREMIUM

15. There is no law
requiring your
employer to
contribute
At least for now

16. #3 – DEDUCTIBLE
THE AMOUNT YOU
PAY BEFORE YOUR
INSURANCE PAYS
Think car insurance

17. Review your health plan booklet
Deductible
applies

18. #4 – COPAYMENT/COINSURANCE
THE AMOUNT YOU PAY
BASED ON THE TYPE OF
HEALTH CARE RECEIVED

19. #5 – OUT-OF-POCKET LIMIT
THE MAXIMUM YOU
PAY ON COVERED
SERVICES BEFORE
YOUR INSURANCE
PAYS 100%

20. #1 – PREMIUM
#2 – CONTRIBUTIONS OR
COST SHARING
MONEY #3 – DEDUCTIBLE
TERMS #4 – COPAYMENT OR
COINSURANCE
#5 – OUT-OF-POCKET
LIMIT

21. PROVIDER
TERMS

22. #6 – IN-NETWORK SERVICES
HEALTH CARE RECEIVED
FROM A PROVIDER WHO HAS
A CONTRACT WITH YOUR
HEALTH PLAN

23. #7 – OUT-OF-NETWORK SERVICES
TREATMENT FROM
PROVIDERS WHO DO
NOT PARTICIPATE IN
YOUR HEALTH PLAN’S
CONTRACTED GROUP

24. Why should you care?
Visiting network
providers keeps
money in your
pocket

25. #8 – PRIMARY CARE PHYSICIAN
A PHYSICIAN WHO
MANAGES YOUR OVERALL
HEALTH CARE
Often your “family doctor”

26. Your health plan may require
Thomas Jones, MD
General Practitioner you select a primary care
physician (PCP)

27. Your health plan may require
Thomas Jones, MD
General Practitioner you select a primary care
physician (PCP)
and receive referrals to
specialists from your PCP

28. If you don’t get the referral
it could cost you
– big time

29. #6 – IN-NETWORK
PROVIDER #7 – OUT-OF-NETWORK
TERMS #8 – PRIMARY CARE
PHYSICIAN

30. PLAN
TERMS

31. #9 – COVERED SERVICES
LIST OF ELIGIBLE
SERVICES FOR
BENEFITS UNDER
YOUR HEALTH PLAN

32. #10 – MAXIMUM ALLOWANCE
THE HIGHEST DOLLAR AMOUNT YOUR
HEALTH PLAN PAYS FOR A SERVICE

33. You could be left holding the bag
for charges from
an out-of-network provider

34. #11 – EXCLUSIONS AND LIMITATIONS
LIST OF NON-COVERED
SERVICES OR THOSE WITH
BENEFIT RESTRICTIONS
UNDER YOUR HEALTH PLAN

35. #12 – BRAND VS. GENERIC DRUGS
DRUG WITH BRAND NAME
THAT IS PROTECTED BY
Brand™ PATENT
Drug

36. #12 – BRAND VS. GENERIC DRUGS
DRUG WITH BRAND NAME
THAT IS PROTECTED BY
Brand™ PATENT
Drug
SAME ACTIVE INGREDIENTS
AS BRAND DRUG

37. Generic alternative saves money
Ask your physician about generic drugs

38. #9 – COVERED SERVICES
#10 – MAXIMUM
PLAN ALLOWANCE
#11 – EXCLUSIONS AND
TERMS LIMITATIONS
#12 – BRAND VS GENERIC
DRUGS

39. MONEY
TERMS
1. PREMIUM
2. CONTRIBUTIONS
– COST SHARING
3. DEDUCTIBLE
4. COPAYMENT –
COINSURANCE
5. OUT-OF-POCKET
LIMIT

40. MONEY PROVIDER
TERMS TERMS
1. PREMIUM 6. IN-NETWORK
2. CONTRIBUTIONS 7. OUT-OF-
– COST SHARING NETWORK
3. DEDUCTIBLE 8. PRIMARY CARE
4. COPAYMENT – PHYSICIAN
COINSURANCE
5. OUT-OF-POCKET
LIMIT

41. MONEY PROVIDER PLAN
TERMS TERMS TERMS
1. PREMIUM 6. IN-NETWORK 9. COVERED
2. CONTRIBUTIONS 7. OUT-OF- SERVICES
– COST SHARING NETWORK 10. MAXIMUM
3. DEDUCTIBLE 8. PRIMARY CARE ALLOWANCE
4. COPAYMENT – PHYSICIAN 11. EXCLUSIONS &
COINSURANCE LIMITATIONS
5. OUT-OF-POCKET 12. BRAND VS
LIMIT GENERIC DRUGS

42. Learn health
Check your Save
insurance
health plan money!
terms

43. Questions? Ask your employer’s
human resource
professional

44. Questions? Ask your employer’s
human resource
professional
Or your health insurance
agent or representative

45. Legal stuff
Notice of Disclaimer –Cathy Miller is not an attorney or health care
provider and cannot provide legal or health care advice.
The information provided is for your general background only, and is
not intended to constitute legal or health care advice as to your
specific circumstances.
We recommend you review legislation with legal counsel and visit
your physician for health care issues.
Photo Credits: BigStock Photo

46. Download ebook
12 U.S. Health Insurance Terms You Need to
Know: That Cost You Money
www.SimplyStatedHealthCare.com/Free-Stuff

47. Cathy Miller, Business Writer
Business site:
www.SimplyStatedBusiness.com
Health care blog:
www.SimplyStatedHealthCare.com