Deciphering the jargon of medical insurance

If you're like me, one of the most uncomfortable things in medical appointment is having to put the paper gown. Is the opening is on the front or back? Am I able to put before the door is opened? Why is the office always so cold? Sometimes I feel equally exposed when not understand certain terms in the pages of the documentation that my insurance provider sends me after going to a routine appointment.


For many people, the language of health insurance can be confusing and even overwhelming. Here are some common terms and their meaning in general that will help you feel more in control when you try to understand your insurance.

Benefits. Conditions or services covered by health insurance plan. They may include services such as doctor visits, medications, visits to the emergency room and medical accessories such as crutches. Covered benefits your plan are defined in the documents of coverage your health insurance plan.
Coinsurance . You and your health insurance provider share the cost of your health care bills. Your share is a percentage (eg 20%) of a service that has coverage. If consult your doctor costs $ 100, then your party, in this case, would be $ 20.

Copayment . A fixed amount of money you pay when you receive a medical service covered under your plan. For example, you can pay $ 15 for each doctor visit or a prescription drug purchases.
Deductible. The amount of money you have to pay medical expenses before your insurance starts to reimburse.

Explanation of Benefits , or EOB . It is a statement (not a bill) that you receive from your insurance provider detailing the medical services that were paid on your behalf. If you were to owe something for services you receive separate bills due.

Network . This is the group of doctors, hospitals and other health care providers that your insurer has contracted for this purpose. Services "within the network" usually cost much less than the services "off the grid".

Open enrollment. A period of the year when you can select from insurance plans available through the Health Insurance Market or Medicare. The open enrollment period for purchase coverage begins in January 2015 runs from 15 November 2014 to 15 January 2015. This is independent of the Medicare open enrollment, which occurs annually from 15 October to December 7th.
Pocket costs . The amount you pay for medical care that is not covered by your insurance company. It includes your deductible, copayments and coinsurance, plus the costs of services that are not covered.
Premium. The amount you pay, usually monthly, for your health insurance coverage.
Preventive care. Services such as mammograms, diabetes screenings and flu shots. Its mission is to prevent health problems or detect disease in its early stages. The health law requires insurers to cover a wide range of preventive services at no cost.

Doctor. The doctor consultations first for most of your medical needs. Some plans may require that you go to a general practitioner before consulting a specialist, such as an orthopedist (doctor of bones and joints) or a cardiologist (heart doctor).

Patient referral. It  is a letter written by your doctor to consult a specialist authorization. Some insurance providers require a referral, while others do not.

Specialist . A doctor or other health care provider who specializes in a specific practice, such as cardiology (heart doctor) or oncology (cancer doctor).
To read the definitions in more detail takes a look at your manual insured health plan or AARP glossary www.MiLeydeSalud.org.
While learning the lingo will not end coveralls paper, at least we not have to feel so exposed when it comes to health insurance.