10 common health insurance terms you need to know

| Emily Delzell

It’s open enrollment time and that means wading through details of health insurance plans, which are typically littered with confusing language.

To help arm you with the information needed to navigate the insurance landscape, here are 10 terms people with psoriasis or psoriatic arthritis need to understand. 

Coinsurance: The percentage of medical costs for covered health services and medications for which patients are responsible after paying their deductible. Coinsurance percentages vary from plan to plan and are often higher within the same plan for out-of-network providers (and sometimes for specialty drugs like biologics). 

Here’s an example of how coinsurance works: If a plan requires a 20 percent coinsurance payment for a medical service that costs $10,000, you would pay $2,000 and the health insurance company would pay $8,000.

Copay: Short for copayment, this is the flat, predetermined fee you must shell out at the time of almost every visit to a health care professional and for each prescription medication. Emergency department visits and procedures like x-rays also usually require a copay. 

In most plans, copays do not count toward the deductible. Copay costs within the same plan vary for different types of health care (primary care visits usually cost less than those with dermatologists or rheumatologists, for example) and for different medications. Check plan details carefully to understand what you could be paying for office visits and necessary medications. 

Deductible: This is the dollar amount you must pay for most health services before insurance covers any costs. Most plans cover the cost of office visits (with a copay, of course) before you reach your deductible. In many plans, fees to out-of-network providers do not count toward deductibles. 

Excluded services: Health care services that a health insurance plan will not cover. 

Formulary: The list of prescription drugs covered by the plan. Check to make sure your needed medications are included. 

Network: The list of hospitals, clinics, health care professionals and suppliers with whom your health insurer has contracted to provide services. In-network providers and services cost less than those that fall out of network. Some plans have tiered networks that require you to pay more for certain providers. 

Out-of-pocket maximum: This is the dollar amount an insurance plan requires you to pay before starting to cover 100 percent of health care costs. Copays, coinsurance and deductibles usually count toward out-of-pocket maximums; out-of-network care and premiums do not. 
Premium: This the amount you or your employer pay each month for health insurance coverage.

Preventive care benefits: Under Obamacare, all federal marketplace plans (and many private plans) must now cover free of charge (with no copay or coinsurance cost) many preventive health care services such as flu and pneumonia vaccines, fall prevention care, screening for blood pressure and certain cancers, and several services for women and children.  

Prior authorization: A decision by a health insurer or plan that a service or prescription drug is medically necessary. Sometimes called prior approval or precertification, preauthorization doesn’t guarantee your insurer will cover the cost. Many plans now require doctors to get preapproval for prescriptions for “specialty” drugs such as biologics that require special handling, administration or monitoring. 

Answers to your insurance questions

Need some more advice navigating the overcomplicated health insurance landscape? Request a free Health Insurance Quick Guide to help get you through this year’s open enrollment period. 

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For more than 50 years, we’ve been driving efforts to cure psoriatic disease and improve the lives of those affected. But there’s still plenty to do! Learn how you can help our advocacy team shape the laws and policies that affect people with psoriasis and psoriatic arthritis – in your state and across the country. Help us raise funds to support research by joining Team NPF, where you can walk, run, cycle, play bingo or create your own fundraising event. If you or someone you love needs free, personalized support for living a healthier life with psoriatic disease, contact our Patient Navigation Center. And keep the National Psoriasis Foundation going strong by making a donation today. Together, we will find a cure.

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