Premium – This is the cost that you and/or your employer pays to the insurance carrier for you to have ACCESS to your plan.
Copay – this is a fixed amount that is set by your insurance company depending on your plan contract with the company. This payment varies between service providers; primary care physicians, specialists, urgent cares or emergency rooms. Copays are not usually applied to your deductible.
Deductible – The amount that the patient is responsible for paying BEFORE your health insurance plan begins to pay for covered medical expenses annually. This amount is determined by the plan you choose and is a CONTRACT between the patient and the insurance company. These amounts are not determined or set by providers, physicians or facilities.
Coinsurance – This is probably THE most confusing term with regards to health insurance. Once you have met your annual deductible, many insurance companies share the cost of care with you. This is called “coinsurance”. If your plan has a 20% coinsurance, then your insurance company will cover 80% of your covered medical expenses. It is important to remember that this only applies after you have met your deductible.
Maximum Out of Pocket Expense
Maximum Out of Pocket Expense – This is the maximum amount that you will have to pay annually via coinsurance and deductible before your insurance plan pays 100% of your covered medical expenses.
EOB (Explanation of Benefits)
EOB (explanation of benefits) – The statement is prepared in accordance to your contract with your insurance provider. It itemizes the services received, the amount your insurance company paid for those services (if any), and the amount you are responsible for. This is NOT A BILL from Texas Emergency Care Centers.
Appeals – When your health insurer says no to paying for your emergency visit or underpays the claim, that doesn’t have to be the final word. There are many times that we will have to appeal how the insurance company processed your claim. The appeals process takes time and often has to be repeated multiple times. We will often need your assistance during this process. We will work as a team to ensure that we resolve the issues as quickly as possible.