Health insurance Medicare Your Coverage Options

A crash course in 5 important health insurance terms

Written by Diane Archer

As if you didn’t already have enough to think about, you need to understand a sea of insurance concepts to keep your health care costs down. Here are five terms you should definitely know.

  1. Premium—what you have to pay each month for your health insurance.
    • If you have Medicare and are receiving Social Security benefits, the government will take your Part B premium out of your Social Security check—nothing to think about there.  But, if you have Part D drug coverage, you’ll likely have to pay that premium by check directly to the insurance company.  And, if you’re buying your own supplemental insurance, you’ll need to pay that premium as well.
    • If you’re in a Medicare Advantage plan, you’ll probably need to pay an additional premium to the insurance company offering that plan.
    • If you have coverage through the Affordable Care Act (ACA), you’ll have to pay that premium but may be eligible for a government subsidy based on your income.  Use this tool from the Kaiser Family Foundation to calculate the amount of your premium that the government will pay for.
  2. Deductible—what you have to pay out-of-pocket for your care before the insurance starts paying. 
    • If you have traditional Medicare, there is a small deductible for your Part B coverage for medical services and a large hospital deductible as well, both of which you’ll have to pay unless your supplemental coverage picks those up.
    • If you’re in a Medicare Advantage plan, an ACA plan, or an employer HMO or PPO, you’ll need to check on deductibles.  Often, insurers charge a deductible for in-network care and a separate deductible for out-of-network care.  And, if you’re premium is very low, your deductibles could be very high.
  3. Copaya fixed fee that you pay for a particular service.
    • If you’re in a Medicare Advantage plan or an ACA or employer plan and seeing an in-network doctor, your copay will be a set amount of money that represents your share of the doctor’s charge.
  4. Coinsurancea fixed percentage that you pay, based on the amount your insurer pays. 
    • If you have traditional Medicare and supplemental insurance, the supplemental insurer will pick up the coinsurance for all the services it covers.
    • If you are in a Medicare Advantage plan or an ACA or employer plan and seeing an  out-of-network doctor, your coinsurance will be a percentage of the doctor’s bill.
  5. Covered services: Insurers only pay for the services they cover.  Before you see a doctor, go to a hospital or use an ambulance, check to make sure that the insurer covers services from those providers and under what conditions.
    • Traditional Medicare covers services from most doctors and hospitals anywhere in America.
    • But, if you are in a Medicare Advantage plan or an ACA HMO or PPO, your coverage for routine care may be limited to your providers in your community. Sometimes, you will need prior approval from the insurer or a referral from your doctor in order for your services to be covered.

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4 Comments

  • I applied for medicare when I turned 65 and they informed me I didn’t qualified. Later on while talking to a friend she commented she couldn’t believed that I had worked paid tax still paying property and income tax and didn’t qualified for midicare. So I applied again in several offices and was informed that (although I had applied and denied) I would have to pay 10 percent for each yr I had not had it. Which would be more than 800.00 dlls per month not covering medicines. I thought it was redicules so I decline. But everyday I come across people that have lived off the system and for generations get all benefit. Some are even on drugs and trafficking and getting walfare checks and getting Medicare. How do you think it makes us Americans that have paid and one by the rules feel. I am so very fed up with the way the government runs this country where people are punish for working, paying there share of taxes every year and get nothing in return for thier effort.

  • Insurance companies are in it for the money. That is why they have lawyers… So they don’t have to pay FOR YOU. The Government is in on this because they make laws to make sure you have insurance.

    The persons I feel really sorry for are the doctors that have to pay to get the education to help, have student loans, and then are mired down with RED TAPE. And patients who get sick. Heaven help us.

    Don’t take any “milk and honey” from the government, it may be filled with small pox…

  • Why don’t people complain about all this nonsense? It is so ridiculous to have to jump through all these hoops for these insurance companies. Their whole reason for doing these things is to cheat us out of what we are paying for. We have been being screwed for so long we don’t even know we’re screwed anymore. I AM SO SICK OF IT!!!!!

    • I would recommend going to the deeatrmpnt of insurance in your state, look at the companies and also ratings of each company. Many companies throughout United States are merging as the larger companies like WellPoint (blue cross) and United Health are currently acquiring smaller health insurance co’s. So if you buy from a smaller company today, tomorrow you might have the larger company anyway. Also, contact your physicians office and ask your provider who they would recommend- ultimately they are the ones who matter as they will be billing the insurance company you pick.

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