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Health Insurance definitions

Health insurance terms explained

PPO - Preferred Provider Organization - An insurance plan that has a network of doctors that allows patients to freely choose which doctors they want to see. This allows greater freedom when making appointments, particularly with specialist doctors. You can even see doctors out of this network, but often times will pay a higher price to do so.

HMO - Health Maintenance Organization - An insurance plan with a “gatekeeper” primary care physician (PCP).  Patients must visit their primary care doctors for MOST issues prior to seeing a specialist.  Acceptions include emergency care and OB/GYN visits.  Your PCP will then refer you to specialists when appropriate. It is unusual to get any coverage from a doctor outside of an HMO network.

Premium - Monthly cost paid by a patient to be a “member” of the insurance plan. Paid regardless of whether or not you have any healthcare fees. This is how insurance companies generate the bulk of their money

Deductible - We tell patients this is like their healthcare Buy-in.  A deductible is a dollar amount you must spend in a given plan cycle (usually a calendar year) before the insurance company will start to pay for a portion of your healthcare services.  

Out of Pocket Maximum - This is a dollar cap on spending during your insurance plan over the course of plan cycle. Once you reach your out of pocket maximum, the insurance company will pay 100% of all healthcare costs for the remainder of the cycle. 

CoPay - A fixed dollar amount that must be paid by a patient at each visit. Usually in the neighborhood of $20-60 in our office, you will pay this each time you have a visit.

CoInsurance - The remaining portion of a healthcare bill you are required to pay once your deductible is met.  This is usually described as a percentage.  Example: Someone with 20% CoInsurance will pay 20% of the bill, and their insurance company will pay the doctor 80%. 

 

Author
Dr. Todd Peterson, DC, Cert MDT. Dr. Todd Peterson Dr. Todd Peterson is a chiropractor and certified provider for Mechanical Diagnosis & Therapy (MDT, aka the McKenzie Method). Dr. Peterson played football at the University of Nebraska, where he was a 4 year letter winner and Academic All American. He briefly played professional football in 2009 before returning to Chiropractic School in 2010. He earned his doctor of chiropractic (DC) degree from National University of Health Sciences in 2013, graduating with Magna Cum Laude honors.

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