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With most medical expenditures, health insurance can be invaluable. But it can also be confusing.

In these final months of the year, you may want to look into using your remaining 2020 health insurance benefits — especially in cases of potentially costly treatments or procedures and in cases when your deductible has been met. Remember, January 1 is the date on which most health insurance plans reset and any unused benefits that are subject to a “use it or lose it” clause expire.

Additionally, the current open enrollment period is the time to explore any changes you may be able to make to your health care benefits for the upcoming year that would help you plan for your care and obtain the best medical coverage plan for you and your family. In order to productively do so, you need to understand the main medical insurance terminology which is applicable to most plans.

In network/out of network: In network refers to health care providers or facilities that belong to a health plan’s network of providers with which it has negotiated a discount and agreed to provide services to the network’s members. When you go to a doctor or provider who doesn’t take your plan, they are out of network and thus will not be covered under your insurance and will be much more costly to you.


Deductible: The amount you owe during a coverage period (typically one year) for qualifying services before your plan begins to pay toward your care. For example, if you have a $1,000 deductible and undergo a $1,500 diagnostic test, the first $1,000 of that bill would satisfy your deductible and your insurance would pay the remaining $500. Note that the plan may set separate deductibles for individuals in a family as well as for the family overall.


Coinsurance or cost-sharing: An all-year-long, across-the-board percentage you pay, after your deductible is met, toward a service or product while the insurer pays the rest. If your coinsurance rate is 20%, for example, and your doctor bills you $100 for an allowed service, you must pay $20 while your health plan pays the rest. Some plans pay 100% for allowed services after the deductible is met.

Copay: A set fee you pay whenever you receive certain kinds of health care services (outpatient surgery or behavioral health sessions, for example) or get prescription drugs. General practitioner copay (primary care of pediatrics) may vary from a specialist copay (pulmonologist, ENT, podiatrist).


Out-of-pocket limit or maximum: The total amount in health care costs (deductible, co-insurance and in some plans per-visit copays) you must pay before your plan will pay 100% of all qualifying costs for the rest of the year. As with the deductible, the plan may set separate out-of-pocket limits for individuals in a family as well as for the family overall.


Pre-authorization/referrals: A requirement set by your plan in which you must first seek approval from the insurer (pre-authorization) or a physician such as your primary care provider (referral) before you receive a specialized service. Failing to do so could result in your claim being denied.


Keep the above in mind when making your insurance and coverage choices for 2021, and should you have any questions, do consult with your medical practitioners prior to obtaining any services

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