What is coinsurance aetna

A copay is like paying for repairs when something goes wrong. What is a premium? Premiums are regular payments to keep your health care plan active. Higher premiums usually mean lower deductibles.

An example of how it works: Trisha, 57, plans on devoting herself to her three grandchildren after she retires. The plan premium, or cost of coverage, will be taken out of her paychecks. Even though her new plan has higher premiums, the deductible and copays will be lower. Read more about how health plans with higher premiums often have lower deductibles. Her new plan will keep out-of-pocket costs predictable and manageable because as a former smoker with breathing problems, she needs to see doctors and specialists regularly.

What is a deductible? A deductible is the amount you pay out-of-pocket for covered services before your health plan kicks in. An example of how it works: Courtney, 43, is a single lawyer who just bought her first home, a condo in Midtown Atlanta.

She loves that her building has a gym and pool because she likes to stay in shape. When she felt a lump in her breast during a self-exam, she immediately had it checked out. Learn how you can save money with a health savings account. What is coinsurance? Coinsurance is the percentage of the bill you pay after you meet your deductible. An example of how it works: Ben, 28, is a security expert living in suburban Philadelphia with his wife and two small boys.

Their 3-year-old recently fell at the playground and broke his arm. Find out how hospital plans can help you cover costs before you meet your medical deductible. An example of how it works: Leon, 34, is a married forklift operator from Jacksonville, FL.

His Primary Care Physician referred him to an orthopedic surgeon. Having these set fees gives Leon peace of mind since he and Leah are saving to buy a kayak.

Member support. Account management. Log in to your member website Find a doctor Find medicine and costs Find a form Pay your premium Get your ID card opens in secure site Check a claim opens in secure site View coverage opens in secure site. The health guide. All health resources Living healthy Understanding health care Managing health. Additional resources. Health insurance rights and resources Contact us Frequently asked questions.

How health insurance works: The ultimate guide By Aetna. Related content. Read More Read Less. How you can make the most of your health plan. You are now being directed to the AMA site Links to various non-Aetna sites are provided for your convenience only. You are now being directed to the Give an Hour site Links to various non-Aetna sites are provided for your convenience only. You are now being directed to the CVS Pharmacy site Links to various non-Aetna sites are provided for your convenience only.

You are now being directed to the CDC site Links to various non-Aetna sites are provided for your convenience only. Aetna is proud to be part of the CVS Health family. You are now being directed to the CVS Health site. You are now being directed to the Apple. You are now being directed to the US Department of Health and Human Services site Links to various non-Aetna sites are provided for your convenience only. If elected, it enables them to keep their coverage when it would otherwise be lost due to:.

This is the percentage of health care expenses you pay after your deductible. Your health plan pays the rest up to any benefit or lifetime maximum. Also known as cost of living adjustment. This is an optional benefit. It goes with some long-term disability plans. It raises the monthly benefit amount each year. The person on disability gets more money based on the cost of living. These raises are given only for a set time period. This is the highest amount of life insurance you can get.

It means you can have both basic and supplemental plans, but only up to this amount. This is when two people live together for a certain amount of time. They think of themselves as married because of the time spent together.

Some states agree and recognize them as married. This is a health problem that happens during pregnancy. It is something that would not happen in a normal pregnancy. It can affect the baby, the mother or both. These are teeth that never existed in your mouth. This is a condition that existed at, or dates from, your birth. This plan helps you control more of your health benefit dollars.

It includes a fund or account that can be used to pay for your medical expenses. Most health funds allow unused dollars to be rolled over from year to year, for as long as you stay in the plan. Some plans allow the fund to go with you, even if you change jobs. This is a term for a new movement in health care. Its goal is to have everyone more involved in their own care. This means people will have more information to make better decisions about their health care. It includes knowing the real costs of health care and taking an active role in managing those costs.

This is a legal agreement. It is between a customer an individual or group and an insurance plan. It lists all details of the plan's coverage. This is a legal term. It is a customer an individual or group who buys an insurance plan from an insurer. This refers to a group health plan. It means costs are shared between an employer and its employees. This is an amount charged to change policies. It must be paid when you change a group health plan to an individual policy.

This means people can buy a policy on their own after they leave a group plan. It may be offered with certain health and life insurance plans. These rules are used to decide which plan pays first for people who have more than one plan. This helps coordinate coverage and allows claim information to be shared by the plans. This way, the plans can avoid duplicate payments. This is the dollar amount you pay for health care expenses. In most plans, you pay this after you meet your deductible limit.

For example, you pay a set dollar amount to your doctor for an office visit. Copays are also used for some hospital outpatient care services in the original Medicare plan. In prescription drug plans, it is the amount you pay for covered drugs.

Also known as copay. This online tool makes it easy to compare costs for office visits, procedures and more at different doctors and hospitals. The estimates are based on your health plan. The tool factors in your deductible, coinsurance and copays. And it shows what Aetna will pay. This is also called the donut hole.

It is the part of the Medicare plan where the member pays for prescription drugs. The plan does not pay. The gap occurs after you reach your initial coverage limit. It lasts until the expenses you pay add up to a certain amount.

These are services or supplies your health plan covers. They are eligible to be paid by your plan. This is a process. It is used to be sure doctors and hospitals meet certain standards. It is also used for other health professionals and facilities. Also known as prior creditable coverage. This term means types of health coverage a person has had.

People sometimes need to prove they have had this so they can be fully covered by a new plan. This applies to people who are eligible for Medicare. It is coverage that is at least as good as the Medicare drug plan. If you have such a prescription drug plan, you can stay in your plan. You will not be charged higher fees if you switch to Medicare later.

This is care that helps people with daily life activities. The person giving the care does not have to be trained in medicine. This care may help people with walking, bathing, dressing and eating. Also called usual, customary and reasonable UCR , reasonable, or prevailing charge. The limit is based on data Aetna receives. The data is based on what doctors charge for the health care service. We receive this data from Fair Health, an independent organization. Check your plan documents for more details: Your health plan documents will tell you how we pay for out-of-network care.

This is the last day a person worked before becoming disabled. For long-term disability, it is the last day the person worked part of a day. This is the date a person becomes disabled. The person must meet the plan definition of disabled. This is a place where people can get mental health care. They don't stay overnight. They visit the treatment provider as needed for care. Also known as date claim incurred.

This is for disability plans. It is the date a person becomes disabled. This applies to life insurance. It is the money that an insurance company pays when an insured member dies. This is what you must pay for health care before the Medicare plan begins to pay. This amount can change each year. There are many different types of these plans. In them, employers give each worker a fixed amount of money. The worker can use the money for retirement, health or some other benefit. When the plan is for health benefits, the money can be used to pay for health insurance or health services.

This is a person who is covered by another person's plan. It can be a child, spouse or domestic partner. You can put money into this account before taxes are taken. You can use the money later to pay for eligible childcare expenses. No taxes are taken out, so you lower your taxable income rate.

The money does not build interest. It cannot be rolled over to the next year. Also, the money cannot be taken from one job to another. These are tests that a health care professional orders.

The tests help see if a person has a condition or a disease. X-rays and ultrasounds are examples of these tests. This is a type of health plan. The plan lets you go directly to a health care professional in the plan's network without a referral. Long-term disability LTD : Employees may have an illness or injury. They may not be able to work for a long time. An LTD benefit through their employer helps protect them and their families from financial loss. It provides a source of income for a set time.

This helps to maintain a percentage of the employees' pre-disability income. See "Other income benefits. Short-term disability: This pays part of workers' pay when they are out of work.

They must be out of work for a short time with an illness or injury that is not related to work. These are services and products. They help businesses track and manage when workers are out. This includes general absences and leaves of absence. This is a type of program that comes with some health plans.

It is used to help people who live with a chronic illness. It helps members manage their health and prevent future problems. Also known as date last worked. For short-term disability, it is the last day a person worked half a day or more.

For Medicare patients: These are devices that doctors order for use in the home. They must be reusable. Some examples are walkers, wheelchairs or hospital beds. This means two people who live together but are not married. They are responsible for each other's well-being and finances. They may or may not be a same-sex couple. Also known as coverage gap. Also known as a formulary. This is a list of prescription drugs the health plan covers.

It can include drugs that are brand name and generic. Drugs on this list may cost less than drugs not on the list. How much a plan covers may vary from drug to drug. An open formulary provides a greater choice of covered drugs. It is also called a preferred drug list. These are groups of different drugs. Usually, the plans group the drugs by price.

Each group or tier requires a different copay. You might see the groups listed as generic, brand-name, or preferred brand-name drugs. Generic drugs often have lower copays. Brand-name drugs have higher copays. These are devices that doctors order for use in the home. Also known as employee assistance program. This can help people balance work and life issues. It gives support and counseling to help people deal with stress, family issues and more.

The program is for employees, their dependents and household members. Employers buy it. Workers do not pay to use an EAP. This is the base pay for calculating disability benefits. The benefits could be short- or long-term. The pay does not include bonuses, overtime or other extra pay. Some types of pay, like commissions, may be offered. It depends on the policy.

This includes terms that decide who can get coverage. The requirements vary. They could include health conditions, how long a person is employed, job status and more. This is the amount of time people must be disabled before they can get long-term disability benefits. The policy states how long the time is. No benefit is payable for or during this period. This is a serious illness or injury. It comes on suddenly. It is something that needs immediate medical care.

If a person does not get care quickly, death or serious health problems may occur. This is a place that offers short-term care on the spot. People usually go to one when they have a sudden illness or injury. Two examples are hospitals and clinics. This is a law. It controls employer-based health plans. It also sets rules for pensions and other benefits plans. This is a digital version of a patient's medical history.

The goal is that all professionals involved in a patient's care enter details into this record. That could be your primary doctor or specialist. Or pharmacies, hospitals and labs.

Patient information can now be easily seen and shared across all providers. So there's a broader view of a patient's health. Also known as a member.

A member is someone who belongs to a health plan. Sometimes a member is known as an enrollee. This is when people can sign up for a Medicare health plan. At this time, the plan accepts people new to Medicare.

The plan must also allow all eligible people with a different Medicare plan to join. Local transportation in a specially equipped certified vehicle from the scene of an accident or a medical emergency to the closest facility that can provide the necessary care.

With respect to an emergency medical condition, a medical screening examination that is within the capability of the emergency department of a hospital and within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required to stabilize the patient.

See "Explanation of Benefits. It shows charges, payments and any balances owed. It may be sent by mail or e-mail. This looks at a person's physical work space. The goal is to make sure it is safe and comfortable. It's important that the equipment a worker uses gives proper support.

Doing this helps lower the risk of work-related injuries. This is an applied science. It calls for creating a physical work setting that fits and supports the worker.

The idea is to help workers be physically safe and comfortable. This is important to workers' health while they do daily tasks. It could mean having the right chair, keyboard or desk, or a headset if a worker has to be on the telephone a lot.

This refers to a set of health care service categories. The Affordable Care Act requires that these categories be covered by certain plans in the individual and small group markets.

The categories include:. Only plans that cover these benefits can be certified and offered in the health insurance marketplace. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid.

This is when doctors use the latest research findings to help them make decisions on patient care. They combine it with their own expertise and what they learn from the patient. A group or individual might have to go through this process when applying for health or life insurance.

EOI may also be needed when someone wants more coverage or is enrolling late. It helps the insurer decide whether to cover the person or group. The process might include:. These are often newer drugs, treatments or tests. They are not yet accepted by doctors or by insurance plans as standard treatment. They may not be proven as effective or safe for most people. This is a statement a health plan sends to a health plan member.

Also known as a death benefit. This can be part of a life insurance policy. It lets insurers pay out some of the benefit before the final claim is settled.

The money can go to a beneficiary. It can also go to a friend or relative. The money is often used to pay for funeral costs or other related costs. This is a law for employers with 50 or more workers. It applies to workers who need to take time off from work for:. Workers can get up to 12 workweeks of unpaid leave per year if they qualify. This law also provides certain rights for members of the military and their families. A measure of income level issued annually by the Department of Health and Human Services.

Federal poverty levels are used to determine eligibility for certain programs and benefits. These are federally funded nonprofit health centers or clinics. They serve medically underserved areas and populations. They provide primary care services. The amount they charge is based on the person's ability to pay.

This is a process used by some health plans. It lets plans pay doctors and other providers a fee for each service they provide. Most federal government workers are covered under it. This is a way workers can set aside money to help pay for health care. An FSA is used with a health benefits plan.

Workers ask for money to be taken from their pay each pay period. This money is not taxed in most states. The money goes into a fund the worker can use to pay for different health expenses. All money must be used by the end of the stated year or it will be lost. This money cannot be transferred to another job or account. Also known as the Family and Medical Leave Act. This is a list of prescription drugs not covered by a health plan. It applies to closed formulary plans. If a member needs a drug on this list, the doctor must ask the plan to cover it as an exception.

The plan will only do so if use is medically necessary. These employers pay the health plan provider to administer and manage the benefits they've chosen. The insurer pays the claims. This means the insurer is the one taking the risk. This exam is done by occupational or physical therapists.

It tests people who have been injured or sick to see if they can return to work. It might test how well a person can lift, bend, stand, climb or carry.

It can also focus on a specific function, like use of the hands. Health coverage Health coverage. Plans through employer.

Options without employer coverage. Student plans. International plans. Dental vision and supplemental Dental vision and supplemental. Dental plans. Find a dentist. Vision plans. Find an eye doctor. Supplemental plans. Pharmacy Pharmacy. Get pharmacy plan information. Find a pharmacy. Find medicine and costs. Medicaid Medicaid.

Medicaid plans. Log in. For employers. For providers. For brokers. About us. Member support. Your member website Your member website. Log in to your member website. Find a form. Pay your premium. Get ID card. Check claim.