A General Overview of Health Insurance

Most, but not all of my patients have health insurance, whether self-funded or employer sponsored. Yet, the vast majority of these people do not understand the basics of their own plan or any of the basic terminology of insurance what-so-ever.

Well, all that changes now.

We are going to go over the true basics of health insurance here, think of it as an insurance 101 course at the University of Dr. Zeccardi. That being said, this article is by no means a comprehensive resource. Just the basics for now. If I receive a strong response and readership, I may dive deeper.

So, just because you have a health insurance plan it does not mean all of the services you want are free. Say it ain’t so doc? Well, it is so people. I cannot express to you how many individuals call the clinic or come in with the assumption just because they have a nice, new, crisp health insurance card that everything is free. You have to read the policy language to truly find out what is and is not covered, what is paid for in full, in part or not all by the insurance company you purchased the policy from / through. Every plan is a little different and can generally be tailored to your particular situation. For example, a single college student without dependents does not require the same plan as a family of 5. So, we purchase the plans according to our needs. Dental services and vision services are usually separate or add-ons to the policy. I said usually, so there are exceptions to every rule here.

Ok, so let’s go over some general vocabulary as it relates to insurance.

Policy / plan – This is what you are buying… The policy outlines what is and is not covered and the rate or percentage of the coverages the insurance carrier provides. Please read the policy language. Yes, it is in legalese and difficult to understand by design. If you need to have a professional read it to you / for you, please do so. Just do not go without reading the policy language, I like surprises in general but not these kinds of surprises. A good and honest insurance agent can be of great help here.

Premium – This is the per month, per quarter, per semi-annual or annual fee you pay for the policy. As you can see the premium payments can be broken down by timeframe to make things affordable. Premiums can also vary in price as you would expect.

Deductible – This is the amount you have to pay out of your pocket BEFORE your insurance kicks in and starts paying for services rendered. Deductible amounts vary wildly. They can be $500 or they can be $25,000. It all depends on the policy / plan you have chosen. As a general rule the higher the deductible, usually the lower the premium cost will be.

Co-pay or co-payment – This is a flat fee you are responsible for at the time of receiving a service. You may even have different co-pay amounts based on who you see or what you get. Your primary care physician and a specialist tend to have different co-pay amounts. Prescription drugs and or durable medical equipment tend to have different co-pay amounts. Every plan will have a different co-pay amount, some have none and some are quite high. $0-$75 is what we see with a $35 co-pay being the average at the time of this writing (January 2021).

Co-insurance – Once your deductible has been met your insurance will start processing claims for the services you have received. Usually there is a shared cost. What I mean by this is there may be an 80/20 or 70/30 or whatever amount split. So, as an example of an 80/20 plan, your insurance company will cover 80% and you are responsible for the remaining 20%. That remaining % is the co-insurance. Your doctor or whomever provided the service tends to send the patient a bill for the co-insurance owed after the insurance company has processed the claim. The amount of time it takes for an insurance company to process a claim also varies so be on the lookout for bills in the mail that can be many months after you received the service. 

Then there are treatment caps, out of pocket maximums, lifetime coverage limitations, per date of service limitations, specialist limitations and much more. Honestly, there is too much for me to get into and even if I chose to do so, you would be asleep in 5 minutes.

Now, here is the thing. Each year the deductibles reset. So, each year it all starts all over again…

There are many different choices as to what company to purchase a health insurance policy / plan through. Maybe your employer chooses the company for you and this may also change each year as your employer or yourself for that matter shop around for the best deal. You also have the “marketplace” which is a governmental virtual storefront to buy subsidized plans that qualify under the Affordable Care Act or the ACA or sometimes referred to as Obamacare. You can purchase direct from the insurance company or go through an agent as well. Then you have numerous plans that the insurance company sells. Each plan will be a little different and here is where you need to take your time and choose wisely. Basically, you have many options for the purchasing of insurance and this article is by no means all inclusive. But it’s a good start.

I hope this helps to clear up the basic vocabulary and definitions for you as it relates to health insurance. Please remember, its confusing by design. When in doubt please give us a call and we can help clarify any misunderstands you may have.

We at North Florida Spine and Injury Center look forward to helping you in the future

Thank you

Dr. Adam Zeccardi DC, FIAMA