DMIS Blog

Whether you have a high deductible Individual Health Insurance plan, a Group plan, or have just purchased a Comprehensive Foreign Health Travel Insurance plan it is important to understand what your plan does and does not cover. This can help prevent big surprises and costly errors when it comes time to use your benefits. For example, some plans provide for a limited number of physical therapy sessions per calendar year. In this case if the member continues past the allowed number of visits without having additional visits pre-approved he or she would be left to pay the entire bill on his or her own even though this is a covered service.

Every industry has its own nomenclature (some would call it jargon) and the insurance industry is no exception. A basic understanding of some of these terms is essential to understanding your policy. With regards to Health, Dental and Vision Insurance here are the general definitions of several important terms.

Deductible: The amount an individual must pay for health care or dental expenses before insurance covers the costs, usually based on a calendar year.

Co-Insurance: Refers to money that an individual is required to pay for services after a deductible has been paid, usually a percentage of the total cost.

Maximum Out of Pocket: The maximum amount of money that the covered person will pay for claims within a specific time period, usually based on a calendar year.

Calendar Year Maximum Benefit: The maximum amount of money that an insurance company will pay for claims within a specific time period, usually based on a calendar year.

Co-Payment: Co-payment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers.

In-Network: Providers or health care facilities which are part of a health plan's network of providers with which it has negotiated a discount.

Out-of-Network: Any providers or health care facilities which are not contracted with the particular health or dental plan.

The best way to begin understanding what your plan does and does not cover is by reading your insurance plan’s benefit summary. The benefit summary is where the insurance company addresses the terms given above and how they interact with each other. Most types of services will be addressed in the benefit summary. For Health Insurance, services such as hospitalization, physical therapy, mental health benefits, and prescription drug coverage will be addressed. For Dental plans, items such as calendar year maximum benefit, dental service co-insurance levels and orthodontia benefits will be addressed.

If further clarification is required you can call your insurance company and request the evidence of coverage (EOC) booklet for your particular policy. Each plan has an EOC document that addresses in detail the benefits listed in the plan summary as well as any additional benefits. Other important information like membership eligibility, exclusions, and contact resources will also be addressed.

Alternatively, if your Individual Health Insurance plan or Group benefit plan was written through an Insurance Broker, you can call him or her for service. This is one of the many benefits of using an Insurance Broker. A qualified Independent Insurance Broker will be able to answer all of you plan benefit questions, help you if a claim dispute arises, and advise you on other available insurance options.

By understanding what your insurance plan does and does not cover and how each piece fits together you can make the most informed decision when it comes time to use your benefits. This will help you avoid any unexpected bills down the road. If you have questions or issues you can’t resolve on your own contact Drew Miller Insurance Services at 831.459.9140 or by email at info(at)drewmillerinsurance.com and ask what we can do for you.