Choosing and Understanding Your Ohio Health Insurance Plan

Choosing a plan / understanding your plan

Before you choose a health plan or to understand the plan you have, check the policy's details. Know how the plan denies the terms shown on this page to have an idea of your possible out-of-pocket costs.

Coinsurance

The amount you pay for a covered service or treatment after the health plan's deductible has been met. Coinsurance is usually based on a percentage.

For example, you might pay 20 percent of hospital charges. If you use network providers, you are responsible for 20 percent of the eligible charges. Network providers have agreed not to bill for anything over the approved amount.

However, if you use non-network providers, the plan would pay its share up to the approved amount only (this may be called "usual, customary, reasonable" or UCR). You are responsible for your coinsurance percentage plus the difference between the approved amount and the billed amount. The difference can be significant.

Copayment

A flat fee you pay for a covered health care service or treatment. Certain types of plans, including HMOs and some PPOs, require a copayment for each office visit to a doctor and often a larger copayment for emergency care. Creditable coverage

Written proof of coverage from your former employer or health insurer which you use to get new insurance. Proof of creditable coverage guarantees that any waiting period the new plan normally imposes before covering pre-existing conditions will be eliminated or reduced. This is important when you change jobs (or insurance plans) and need pre-existing conditions to be covered right away.

Deductible

The amount you pay for medical bills before your plan begins to pay. Normally, a larger deductible means a less expensive policy.

Explanation of Benefits (EOB)

A statement from your health insurer that shows amounts it has paid and amounts it has not paid for a claim. If you want to challenge the company's payments, it's important to make sure you get all the EOBs that apply to the claim and keep them organized.

Lifetime maximum

The maximum amount your health insurance will pay for covered services during your lifetime. Look for the highest lifetime maximum you can ind to guard against a catastrophic illness or accident.

Out-of-pocket maximum

The amount of coinsurance / copayments you must pay yourself before your health plan starts paying 100 percent of your covered medical bills. This amount may or may not include the deductible and likely does not include penalties and many out-of-network charges.

Premium

The amount you pay to the insurance company in exchange for providing coverage for a specified period of time under a contract. Premiums are usually paid for a one-month period but can be scheduled for annual or quarterly payment.