8 Health Insurance Terms You Should Know
Last updated: September 2021
Aside from paying your monthly premium, health insurance is something you rarely think about when you’re healthy. But when you’re diagnosed with lupus, you will frequently need to call your provider, review new health insurance plans to see what fits your needs and make decisions about premiums vs. deductibles. Navigating the ins and outs of health insurance after you are newly diagnosed can feel like being dumped onto a foreign planet with its own alien language. Below is a list of terms with definitions that can guide you through this foreign land while empowering you to take control of your healthcare.
HMO stands for “health maintenance organization”, meaning the insurance company organizes a group of medical specialists for your care. An HMO plan is a type of plan in which the doctors you visit have to be “in-network.” If you have an HMO plan, always check to see if a doctor is in-network. Otherwise, you might be hit with a surprise bill afterward.
In-network refers to a doctor or facility that your HMO health insurance approves of and has agreed to pay for their services. The list of approved doctors is called a network. Both the doctor’s office and your health insurance provider should be able to tell you if a particular doctor is in-network.
PPO stands for "preferred provider organization." This means that your health insurance will partially cover appointments or procedures with doctors on its preferred provider list. The major difference between HMO and PPO is that PPO will cover a portion of your visit to a non-preferred provider, although your copay might be more expensive.
Your Premium is the set, unchanging amount that you pay each month to keep your health insurance. If you have at least one diagnosed condition or chose a plan with more than minimum hospital coverage, your premium is, unfortunately, likely to be higher.
The Deductible is the amount of money you need to pay out of pocket before your insurance kicks in and covers the remaining cost of your treatment. High deductible plans require you to pay a higher amount for treatments, usually in the thousands but are often paired with a lower monthly premium. A high deductible low premium plan might be good for someone who does not anticipate having many medical treatments in a given year.
A copay is a portion of the cost of a doctor’s visit or procedure that you pay yourself instead of your doctor billing your insurance. Sometimes copays are a percentage of the visit or procedure, but more often they are fixed amounts. For example, a visit to your General Practitioner might cost $25, while an appointment with a specialist might cost $75.
Medicare is government-funded insurance for seniors over 65 years of age or for disabled Americans that qualify. While there are different plans you can choose, Medicare is overall excellent healthcare. The monthly premiums are low, copays are often $5 or less, and prescriptions tend to be inexpensive. Medicare is divided into 3 parts:
There are perks to being on Medicare. Some gyms allow free entrance to seniors on Medicare, which is a program called the Silver Sneakers.
Medicaid is government-funded insurance for low income earners. Medicaid plans and the income requirements for being on them differ by state.
Have there been things you have learned along your lupus journey that you wish had been explained to you by a healthcare provider earlier?