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Your Benefits Connected! Insurance Jargon 101

Making the connection to engage in your wellness means understanding insurance terms and costs.

And we know that's not easy.  

It's hard enough to find the time for preventive healthcare and even harder if the process seems confusing and we're not sure what our costs may be. 

This brief read connects common insurance terms so you can breathe a little easier through your open/switch enrollment process. 

What is a premium?

Your premium is the amount you pay for your health insurance or plan each month.  When you enroll in an APS medical plan, you are also covered under the prescription/pharmacy benefits provider Express Scripts. 

What is Copayment?

Or copay, for short, is the amount you pay as your share of the cost at the time of service. This can be for a primary care/doctor visit or other specialty medical visits like orthopedics, surgeons, chiropractor/physical therapy, Urgent Care, or ER.  You also have copays on prescription drugs.  Generic medication options will cost you less than brand drugs. 

Urgent care and Emergency Room (ER) copays are higher and more expensive.  

Typically, preventive services like vaccinations, annual exams, mammograms, colonoscopies, and mental/behavioral health services listed in your 2023 comparison grids do not have a copayment unless you go to an out-of-network doctor or medical facility.

What does deductible mean?

This is the amount you owe for covered health services before your health insurance plan begins to pay. Once you reach your deductible, coinsurance will start.

What is coinsurance?

Your share of the cost of covered health care and prescription drug services. Usually calculated as a percentage of the allowed amount for the service. For example, if you have a covered medical expense from an in-network provider that is $100 and your coinsurance is 20%, then you pay $20 and your employer plan pays $80. With out-of-network providers, you may have a higher percentage of cost-sharing for coinsurance, or no cost-sharing, in which case you are subject to pay the total cost and it will not go toward your out-of-pocket limit/maximum.

This is an important point for you to be aware of using doctors, hospitals, and other medical facilities that are in-network versus out-of-network. Depending on the health plan you choose, there may be different access to doctors and medical services available to you. Out-of-network provider expenses typically do not apply to your out-of-pocket maximum (or out-of-pocket limit).

What is out of pocket maximum or limit?

This is a cap, or limit, on the amount of money you have to pay for covered health care services, and prescription drug services (separate limit applies), in a calendar year. If you meet that limit, your health plan will pay 100% of all covered health care costs for the rest of the calendar year. Some health insurance plans refer to this as an out-of-pocket limit. 

Upcoming Webinars

 Again, we are hosting several webinars on Your Benefits-Connected! Sept. 27-30, Oct. 4. Check the schedule for topics and times. Reach out with questions at employee.benefits@aps.edu or submit questions online.

*Sources healthcare.gov, APS 2021 Enrollment Guide