Key Health Insurance Concepts

Lab or Pharmacy Fees

Fees billed and paid separately for testing like blood work, GBS swabs, etc., or for medications or medical equipment, like prescriptions.

Deductible

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.

Premium

The amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance.

Facility Fee

A facility fee is a charge that you may have to pay when you see a doctor at a clinic that is not owned by that doctor. Facility fees are charged in addition to any other charges for the visit. Facility fees are often charged at clinics that are owned by hospitals to cover the costs of maintaining that facility.

Family and Medical Leave Act (FMLA)

A federal law that guarantees up to 12 weeks of job protected leave for certain employees when they need to take time off due to serious illness or disability, to have or adopt a child, or to care for another family member. When on leave under FMLA, you can continue coverage under your job-based plan.

Copayment (co-pay)

A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible. Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20. If you've paid your deductible: You pay $20, usually at the time of the visit. If you haven't met your deductible: You pay $100, the full allowable amount for the visit.

Health Savings Account (HSA)

A type of savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses. A Health Savings Account can be used only if you have a High Deductible Health Plan (HDHP). High-deductible plans usually have lower monthly premiums than plans with lower deductibles. By using the untaxed funds in an HSA to pay for expenses before you reach your deductible and other out-of-pocket costs like copayments, you reduce your overall health care costs. HSA funds roll over year to year if you don't spend them. An HSA may earn interest. You can open an HSA through your bank or other financial institution.

Flexible Spending Account (FSA)

An arrangement you set up through your employer to pay for many of your out-of-pocket medical expenses with tax-free dollars. These expenses include insurance copayments and deductibles, and qualified prescription drugs, insulin and medical devices. You decide how much of your pre-tax wages you want taken out of your paycheck and put into an FSA. You don't have to pay taxes on this money. Your employer's plan sets a limit on the amount you can put into an FSA each year. There is no carry-over of FSA funds. This means that FSA funds you don't spend by the end of the plan year can't be used for expenses in the next year. An exception is if your employer's FSA plan permits you to use unused FSA funds for expenses incurred during a grace period of up to 2.5 months after the end of the FSA plan year.

Global Professional Fees (specific to maternity care)

Global Professional Fee as related to maternity care is reported when a clinician from an individual or group practice provides the global routine obstetric care, which includes the antepartum care, delivery, and postpartum care. Providers are reimbursed a global payment for the total clinical services related to the pregnancy from the initial diagnosis of the pregnancy until the end of the postpartum period. The provider is reimbursed at the global fee for all clinical services regardless of the number of office visits or possible complications with the pregnancy. Note: Other visits or services within the antepartum care, such as diagnostic tests, laboratory services (excluding urinalysis), and radiology services are billed to client separately.

Out-of-Pocket Maximum

The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. The out-of-pocket limit doesn't include your monthly premiums. It also doesn't include anything you spend for services your plan doesn't cover.

Coinsurance

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%. If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest. If you haven't met your deductible: You pay the full allowed amount, $100.

Open Enrollment Period

The yearly period when people can enroll in a health insurance plan. Outside the Open Enrollment Period, you generally can enroll in a health insurance plan only if you qualify for a Special Enrollment Period. You're eligible if you have certain life events, like getting married, having a baby, or losing other health coverage. Job-based plans may have different Open Enrollment Periods. Check with your employer.