Knowledge is power. If you are trying to decide what health insurance plan you need, its important to have a basic understanding of the language. By being informed, you will be able to navigate health insurance easier and discover which plan will be right for you. Having a basic understanding is an essential part of the insurance coverage process, but it should be accompanied by having an agent who can show you how to use it. Cosmo Insurance Agency’s health insurance brokers in New Jersey will be the guide you need to get the coverage right for you, whether it is individual or group. Contact us today so that we may help you get your foot in the door!

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Basic Terms

Coinsurance
The percentage of the cost that you need to pay for a covered service.

Copay
The fixed dollar amount you pay to a health care provider for a covered service at the time care is provided.

Deductible
The dollar amount an individual or family pays for covered services before your plan pays any benefits within a calendar year. Your plan has both in-network and out-of-network deductibles. These deductibles accumulate separately and are not combined.

Deductible Carryover
A feature of your plan that allows for any portion of your deductible that is paid during the fourth quarter of a calendar year to be applied toward the  next year's deductible.

In-Network Services
Refers to services received from an extensive network of highly qualified physicians, and health care providers available to you by your plan.  Generally, your out-of-pocket costs will be less when you receive covered services from in-network providers.

In-Network Provider
A physician or provider of health care services who belongs to the health plan in-network provider panel. To find an in-network provider, refer to the  plan’s provider directory.

Out-of-Network Services
Refers to services you receive from a non-network provider. Your out-of-pocket costs are generally higher when you receive covered services from  non-network providers.

Out-of-Network Provider
Any health care professional who does not participate within your health plan’s in-network panel of physicians and providers of health care  services.

Out-of-pocket Maximum
The limit on the dollar amount you will have to spend for specified covered health services in a calendar year. Some services and expenses do not  apply to the out-of-pocket maximum. See your Member Handbook for details.

Prior Authorization
Some services must be pre-approved. In-network, your provider will request prior authorization. Out-of-network, you are responsible for obtaining  prior authorization.

Usual, Customary & Reasonable (UCR) 
Describes predefined charges established by your plan for services that you receive from an Out-of-Network provider. When the cost of Out-of-  Network services exceeds UCR amounts, you are responsible for paying the provider any difference. These amounts do not apply to your out-of- pocket maximums or maximum cost share.

Medical Plan Characteristics

Preferred Provider Plan (PPO)

·         Access to a nationwide directory of preferred providers

·         Does not require designated primary care provider

·         Co-insurance (percentage of usual, customary and reasonable rates)

·         Does not require referrals to specialists

Coordinated Care Plans

·         Only available in certain counties

·         Requires pre-designation of medical home or primary care physician

·         Co-payments (fixed amount) and do not accrue towards Out-of- Pocket maximums

·         Requires referrals to specialists

Health Maintenance Organization (HMO)

·         Only available in certain counties

·         No deductible

·         Access care only through Kaiser facilities

·         Co-payments (fixed amount)

·         Requires referrals to specialists














Source: http://www.oregonhealthbenefits.com/oregon_health_insurance_coverage?keyword_session_id=vt~adwords|kt~%2Bhealth%20%2Binsurance%20in%20%2Boregon|mt~b|ta~{creative}&_vsrefdom=wordstream

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