American Medical Terminologies Hat

Analyzing the healthcare system can be daunting. At times, it can be hard to make sense of it—especially when it comes to American healthcare.

Healthcare Practices and Insurance Policies contain the following concepts:

The Patient's Portion of Costs

This is the total amount that you personally settle irrespective of the insurance coverage. At the doctor’s office, your deductible is $1,000. Given that, you as the patient, pay the $1,000 deductible and from that point on, the patient’s insurance coverage is activated. You as the patient, pay the $1,000 deductible and from that point on, the patient’s insurance coverage is activated.

To the extent that the deductible is higher, the premiums are likely to be lower. However, if you are sick, you are bound to pay in cash irrespective of premiums.

A copayment

This is you paying a fixed amount for a service, the balance being settled by the insurance in some of the instances.

Such instances are in prescriptions for medication and charging patients for office visits.

Co-Insurance

This is the patient’s part of the payment that is settled with the patient’s insurance. You pay 20%, while the patient’s insurance covers the remaining 80%.

This is relevant when one is making a claim and co shares the claim with the insurance.

Emergency Medical Services

This is termed as walk-in clinics for urgent non-aboratory or non-examination situations such as infections, arm or leg fractures, and certain low-grade fevers.

This is the self payment portion of your insurance claim.

Emergency Room (ER)

Costs A LOT but is always open. Only goes for real emergencies.

For serious or life threatening condition (chest pains, severe injuries, breathing issues)

Premium

You have to pay the premium even if no healthcare is used.

The amount you pay for your insurance every month is called the premium.

The Maximum Out-of-Pocket

The total amount you spend in a year for the covered services (deductible, co-insurance, co-pays) is your annual maximum.

You reach the cap and your insurance covers all the remaining 100% expenses for covered services.

In-Network versus Out-of-Network

In-Network: Lower rates.

Out-of-Network: Much higher price and is often covered partially or not at all.

Example:

You have a $20 co-pay, a co-insurance of 20% and a deductible of $500.

If you go to Urgent Care and the charge is $200, since it is below the deductible, you pay all.

The subsequent visit you pay $500. You pay $300 and 20% of the remaining $200 which in total is $40 to complete the deductible. Insurance covers $160 which you do not pay.

Student Tip:

For urgent care, go for minor injuries.

For severe injuries, go to the emergency room.

When it comes to affordability, always ensure that your physician or practice is in-network.