Ohio Health Insurance

A major difficulty when evaluating health insurance coverage offered in the Cleveland-Akron Corridor of Northeast Ohio is the terminology used to describe various features of the health insurance plans. Here are the definitions of a few important terms:

Annual deductible:

The amount the health insurance plan member must pay out of pocket during a year before the insurance company will begin paying benefits (excluding those services for which you have a co-pay).

Coinsurance:

The amount—usually a percentage—of the Ohio state health insurance bill that the policyholder is responsible for paying after the deductible has been met.  The most common coinsurance is 20% (as in 80/20 plans).

Co-payment:

A common feature of HMOs and PPOs, the co-payment is the flat fee that a health insurance policyholder must pay for medical service or prescription medication. The plan member must make the co-payment at the time the medical service is provided or the prescription medication is purchased. Many plans require a co-payment of $25-$35 for a visit to the doctor’s office. The Ohio health insurance provider is responsible for the remainder of the office visit charges.

Covered expenses:

The services, procedures, drugs, and supplies that the health insurance pays for.

Flexible spending account (FSA):

A savings account provided by employers that allows an employee to set aside a portion of their pre-tax pay for the purpose of paying their share of health insurance premiums and/or medical expenses not covered by the health insurance plan. An employer also is allowed to contribute to the employee’s FSA . Funds in the FSA typically must be used within a benefit year, or else they will be forfeited. Compare to Health Savings Account (HSA).

Group health insurance:

A health insurance plan purchased by an employer to provide health coverage for its employees and members of their families.

Health Maintenance Organization (HMO):

A managed care organization that offers medical services through a network of healthcare providers who have a contract with the organization. An HMO pays only for care given by doctors and other medical professionals who have agreed by contract to treat patients according to guidelines stipulated by the HMO.

Health savings account (HSA):

A savings account into which an employer, an employee, or both can deposit funds for the purpose of paying medical expenses. The funds in an HSA can roll over from one year to another, tax-free, provided they are used for medical purposes or are taken out of the account after the account holder has reached age 65. The HSA account holder must enroll in a High Deductible Health Plan (HDHP) with deductibles of at least $1,100 for one person or $2,200 for a family.

Maximum out-of-pocket costs:

The upper limit that the Ohio health insurance policyholder is required to pay toward medical expenses before the health insurer takes over all payments. Out-of-pocket maximums include deductibles and coinsurance, but usually do not apply to co-pays.

Medicare:

A federal government program that provides taxpayer-funded health insurance for qualified individuals. To qualify for Medicare, a person must be 65 years old or have a qualifying disability. Medicare offers two plans: Part A and Part B. Part A pays for hospitalization. It is funded entirely with taxpayer money. Part B pays for medical services. It is funded by both the Medicare policyholder and the government.

Portability:

The ability to move from one health plan to another despite pre-existing medical conditions.

Preferred Provider Organization (PPO):

A managed care plan that pays a larger portion of healthcare charges when the policyholder accesses services from a physician, laboratory, or clinic inside the network of preferred healthcare providers. The policyholders must pay a larger portion of fees when obtaining services outside the preferred network.

Pre-existing condition:

A medical condition diagnosed prior to enrollment in a health insurance plan. Ohio health insurance companies may exclude treatment for pre-existing conditions for a certain period of time after enrollment or may deny coverage altogether.

Supplemental medical insurance:

A health insurance policy purchased to provide more coverage than is provided by a policyholder’s primary health insurance policy.  These plans are most commonly purchased to supplement the benefits of Medicare.