Coinsurance: This form of payment is similar to copays, but instead of a flat-fee you pay a percentage of the cost of service or prescription. The percentage varies with insurance plan.
Copay: Flat-fees that you pay during a visit to a health provider, healthcare service or for prescription medications, these vary by insurance plan.
Deductible: An amount of money you have to pay for your healthcare service, procedure or treatment before your insurance company starts covering it. For example, a 2,000 dollar deductible means you pay up to that amount and then your insurance starts paying and you are only responsible for a copay or coinsurance for those covered services. Deductibles are normally applied to a calendar year.
Explanation of Benefits (EOB): A statement from your health insurance plan describing the care your insurance policy covers.
In-Network Provider: An in-network healthcare provider is a professional you can see for as little as a copay or coinsurance. Your insurance company has a contract with in-network healthcare provider, so they’ll charge you less for their services.
Insurance: An arrangement where an agency run by the government or private company agrees to pay the full or partial price of medical services. You, in exchange, pay for a monthly fee called a Premium.
Medical Necessity: This is important when getting prior approval from your insurance. The insurance company makes the decision whether to give prior approval based on the medical necessity of the service.
Out-of-Network Provider: An out-of-network healthcare provider is a professional that your insurance company does not have a contract with. In other words, a profession who is not in-network. These providers tends to be more expensive to see because they may require a high copay or not be covered by your insurance at all.
Pre-existing condition: A preexisting condition is a condition for which you have received treatment or diagnosis before you enrolled in a new health plan.
Precertification: Prior authorization, prior approval, and precertification are all terms describing the decision from health insurers to either cover your service or not. This decision is on the basis of its medical necessity.
Premiums: Payments to the insurance company for your policy that are monthly, quarterly, semi-annually, or annually in order to receive all of the benefits that come with your plan. The amount varies by insurance company and plan chosen.
Referral: Depending on your plan, your PCP may be required to write a referral or make a phone call to your insurer before you receive specialty medical services, for example psychiatry or therapy. A referral is a type of precertification.
(State) Children's Health Insurance Program ((S)CHIP): A federal-state health insurance program that covers children with families that have an income that is too high to qualify for Medicaid but are still unable to purchase private insurance. Provides comprehensive health insurance to children until they are 18.
Medicaid: Medicaid is a federal-state health insurance program available to people with low income. This programs covers children, pregnant women, the blind/disabled, and any other persons that meet the income criterion.
Medicare: Medicare is a Federal health insurance program for people who are at least 65 years of age and certain younger people with disabilities.
Military Insurance: An insurance program that is available if you are/have been in the military or have a direct family member that is in the military.
Private Health Insurance Company: Companies that are privately owned and issue insurance policies to cover your healthcare costs. Each insurance company has different plans at different tiers (platinum, gold, silver and bronze) which refer to the portion you are responsible to pay for each healthcare service and the premium of the policy.
State Corrections or Juvenile Justice Funds: Refer to the funds allocated by state corrections or juvenile justice facilities to provide healthcare for their inmates comparable to the care they could receive if not incarcerated.
State Education Funds: Health insurance programs offered to students attending state universities. The care may be restricted to the university's own clinics or teaching hospitals.
State financed health insurance plan other than Medicaid: Includes health insurance programs funded by the state government that are not categorized under Medicaid. These health insurance plans vary greatly from state to state and are usually in the form of state-run facilities that serve individuals that meet the poverty guideline requirements.
Student Health Plans: Most colleges require students’ to have health insurance, so they offer a variety of options. You can stay in your parent’s insurance and notify the insurance company about the change in state if applicable, switch to an on-campus health insurance plan endorsed by the university, or a private health insurance plan. Also, at most universities you can receive healthcare services at the health center that are automatically covered completely or partially by the campus plan; mental health services are included.
Exclusive Provider Organizations (EPOs): EPOS allow you to seek specialty care, such as psychiatrists, within their network without a referral from you Primary Care Physician (whose service costs are also covered by the EPO) . However, you have to pay out-of-pocket when going to a healthcare provider outside of their network.
Fee for service: A payment model where services are unbundled and paid for separately. Payments are only issued after the service has been provided and are for each separate service (for example: office visits, tests, procedures, or other healthcare services). When using a Preferred Provider Organization (PPO) plan, less money is paid out-of-pocket and typically does not require filing claims or paperwork. When fee for service plans are provided by insurance outside of a PPO, the health plans will either pay the medical provider directly or reimburse you after you have filed claims for each of the covered expenses.
Health Maintenance Organizations (HMOs): A type of health insurance plan where subscribers pay a monthly fee in exchange for health services from healthcare providers registered with the organization. These healthcare providers agree to meet a determined quality of care and lower their prices for people insured by the organization. The Insured is required to select a Primary Care Physician within the network who then serves their basic healthcare needs. HMOs do not cover services from Healthcare providers outside their network.
High-deductible Health Plan / Health Savings Account:: In a High-deductible Health Plan (HDHP), you pay a higher deductible than most health plans but pay a lower premium. When you need a healthcare service, you first pay out of pocket, then the insurance company will help you cover the medical costs. Usually people will combine a HDHP with a Health Savings Account (HSA). With an HSA, your pre-tax money that you put in this savings account will contribute to health costs not covered by insurance, such as coinsurance, copays or dental care. For reference, those with employer-based health insurance are eligible to combine HDHP and HSA.
Indemnity Health Insurance Plans:: Indemnity plans are known as “fee-for-service” plans. Under an indemnity plan, you are able to see any specialist you like. Usually you will pay an upfront out-of-pocket fee, and then file a claim to be reimbursed for the covered amount by insurance. You are typically responsible for deductibles and coinsurance costs.
Medicaid Managed Care : An arrangement between a state Medicaid agency and Managed Care Organizations (MCOs) to cover all or most Medicaid-covered services for their Medicaid enrollees. Medicaid recipients may be enrolled in a private healthcare plan where the state pays the fixed monthly premium. Most states now offer Medicaid through these programs and the majority of Medicaid beneficiaries are enrolled in managed care. If enrolled in a Medicaid Managed Care plan, it is important for the recipient to know which private insurance company their plan is enrolled in order to contact regarding their benefits.
Point-of-Service Plans (POS): POS gives the you access to healthcare providers outside of the network for a slightly higher fee. However, you are required to have a Primary Care Physician and must have your Primary Care Physicians (PCPs) write your referrals.
Preferred Provider Organization (PPOs): In PPO Health plans, you pay a set monthly fee and are insured to go to healthcare providers who are registered with the organization as well as healthcare providers who are not. PPOs, however, offer little to no coverage when you go to a healthcare provider outside of the network. People who are insured under PPOs do not need to have a Primary Care Physician.
Private Health Insurance: Private Health Insurances are companies that are privately owned and agree to pay for some of your health expenses in exchange for a monthly premium.
Qualified Small Employer Health Reimbursement Arrangements (QSEHRAs):: A QSEHRA is a health insurance plan designed for small businesses with fewer than 50 employees. A QSEHRA offers employees a monthly allowance of tax free money. Employees then choose and pay for the healthcare services they want, and this includes their individual health insurance policy. Employees file for reimbursement, and the business will reimburse them up to their allowance amount.
Cash: Payment in coins or notes, as distinct from checks, money orders, or credit/debit.
Credit/Debit: Payment cards that can be used instead of cash.
Formal Payment Plans: An arranged payment agreement where the consumer pays a set amount of money at a predetermined frequency until the bill has been fully paid. These plans are usually offered by hospitals, or collection agencies.
Health Credit Card: Payment cards that can help consumers pay for their medical bills. These cards are offered by some banks (e.g Wells fargo, Chase, Citi) and by some health insurance companies (e.g Humana).
Loans: A sum of money borrowed through some form of loan agency that is to be paid back with interest.
Out-of-Pocket: Paying out of pocket means that rather than using an insurance plan, you cover the full cost of your care. The payment goes directly to your provider (keep in mind some providers only accept this method of payment and do not accept insurance).
Paypal: A payment system that allows for online money transfers and serves as an electronic alternative to traditional paper methods like checks or money orders. https://www.paypal.com/us/home
Access to recovery (ATR) voucher: A voucher available for individuals who have a history of drug or alcohol abuse, are looking for support or treatment, and meet the qualification criterion to receive an ATR. The ATR allows patients to choose from a wide varieties of services and facilities that will help with the treatment and recovery. ATR programs are state and federally funded vary from state to state. To find out more about this program and where is offered, please visit https://www.addicted.org/drug-alcohol-rehab-centers-with-access-to-recovery-programs-in-the-united-states.html
Charity Care Programs: Cover medically necessary services for people who cannot afford to pay for treatment and it is program run by hospitals. Also called Financial/Bridge assistance programs.
Federal, or any government funding for substance abuse programs: Programs that are funded by government in order to provide access to substance abuse treatment services. The amount of funding given is based on financial need.
Grants from Nonprofit and Government Agencies: Some nonprofit and government agencies are given funds which they can then use to fund mental health programs and help individuals that meet requirements pay for mental health services.
IHS/Tribal/Urban (ITU) funds: Funds that are available for Native Americans for a variety of services including physical and mental healthcare. To learn more about these funds and how to access them, contact the Indian Health Service in your state.
Local Assistance Programs: These programs are meant to assist individuals who are having trouble paying for their health services and they are usually funded by state and local governments.
No Payment Needed: Services for which no payment is needed are typically available from non-profits or charitable organizations that have therapists, psychologists, or psychiatrists who donate their time and see patients for no cost.
Sliding Scale: This means that funding and payment assistance is based on income and need. Most payment assistance provided by hospitals, nonprofit programs, and federally funded programs are provided on the basis of sliding scale.
State welfare or child and family services funds: Provide support and funding for a wide array of services, including medical services, for eligible children and families.
U.S Department of VA funds: Funds granted to US veterans to help support their healthcare expenses. Most non-service connected veterans without a special eligibility such as a Purple Heart are required to complete a financial assessment at the time of enrollment to determine if they will be required to pay copays.