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Navigating the insurance lexicon

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By Tom Koebel, Regional Vice President, Commercial Sales, Versant Health

Insurance can be tricky place to navigate. Much like any field or discipline, it has its own set of terminology. The following list will help you to navigate the insurance lexicon so you can better understand your vision and eye care benefits.

Coinsurance coverage
A pre-determined percentage you pay each benefit period, after you’ve met your deductible. This pertains to covered services and is paid in addition to your copay. For example, if you plans covers 85% of your costs, you’ll be responsible for the remaining 15%. This 15% is your coinsurance.

Copay

The amount you pay to your eye care professional when you receive a service. Depending on your plan, you may or may not have to pay a copay at each covered visit to your eye doctor.

Coverage

Coverage refers to services or supplies that your vison plan pays for. Coverage may be limited if you received services or supplies from an eye care professional or supplier that is outside of your plan’s network.

Deductible

The predetermined amount you pay for your vision health care before your vision insurance provider pays. For example, if you have a deductible of $1,000, you’d need to pay the first $1,000 of vision care expenses. After you reach that amount, your vision insurance would cover the remainder.

Dependents

Dependents include a spouse and / or children of the insured person / member.

Exclusions

Exclusions are services or supplies that are not covered by your insurance plan.

Eye care professional

Sometimes referred to as a provider, an eye care professional is a person licensed to administer eye care, usually an optometrist or ophthalmologist.

FSA (flexible spending account)

An FSA allow you to use pre-tax money for medical costs and dependent care that falls outside of your insurance plan. It is set up through your employer’s plan and must be used by the end of the term-year of your insurance. Common approved uses for an FSA include:

  • Copays
  • Dental and orthodontic costs
  • Addiction treatment
  • Vaccines / flu shots

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal law that protects the privacy of your medical information and limits healthcare providers and insurance companies from sharing personally identifiable information about patients / members. HIPAA also allows you to instantaneously qualify for comparable health insurance coverage if you change your employment or dependent relationships.

HMO

A health management organization (HMO) provides insurance coverage with a prescribed list of doctors who are under contract with that particular HMO. If you use a practitioner outside of your HMO, those services will likely not be covered, save for certain emergencies.

HSA (health savings account)

An HSA is literally a savings account to be used for health costs. When money is deposited into an HSA, it is not subject to federal income tax. Unlike an FSA, money in an HSA does not have to be spent in a single year and can be used year to year. HSAs must be paired with certain high-deductible health insurance plans in order to be used.

Managed vision care

Vision insurance that works to manage the quality and cost of eye care services.

Medically necessary

Services and / or supplies needed to diagnose or treat a medical condition. To determine this, insurers have to decide if the care is:

  • Accepted as standard practice.
  • Needed versus a convenience for the member or the eye care professional.
  • The right amount and / or level of service needed.

Member

A person covered under an insurance plan.

Network

A group of eye care professionals, hospitals and other health care professionals that have agreed to provide services to vision plan members at a discounted rate.

Out-of-network

An eye care professional, hospital, lab, and / or service provider that has not contracted with a vision plan to provide eye care services at discounted rates.

Out-of-pocket

Out of pocket refers to the amount you pay in any given benefit period. Out of pocket may include deductibles and coinsurance totals. The costs vary from plan to plan and come with a maximum amount.

PPO

A preferred provider organization (PPO) provides more extensive coverage of services from healthcare professionals in the plan’s network, as well as coverage for some healthcare professionals who are out of network. Premiums for a PPO tend to be higher for this increased flexibility.

Premium

Premiums are paid to your insurance carrier to maintain your coverage.

Provider Provider often refers to a healthcare professional, i.e. a doctor. At Versant Health, we prefer the term eye care professional.

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