How health insurance works

Ascension Personalized Care is an EPO. EPO stands for “Exclusive Provider Organization.” It is often called a narrow network. It has an exclusive network of doctors and providers. Coverage is only limited to network doctors. An EPO does allow the member to visit any doctor in their network without a referral from their primary care provider.  

EPO stands for “Exclusive Provider Organization.” It is often referred to as a narrow network. It is similar to an HMO (Health Maintenance Organization) in that it has an exclusive network of providers and doesn’t cover most out-of-network care. However, an EPO allows the patient to visit any provider in their network without a referral from their PCP (primary care provider).

PPO is a Preferred Provider Organization. PPOs offer a larger network of doctors and hospitals to choose from. However, out-of-pocket costs are generally higher.

HMO is a Health Maintenance Organization. This type of plan offers a local network of doctors and hospitals but requires a referral from a PCP to visit other providers. HMOs usually have a lower monthly premium.

Members of the Ascension Personalized Care plan will have access to all Ascension sites of care and providers in their region.

• Members who live in Indiana will have access to 11 Ascension hospitals and over 1,000 providers.
• Members who live in Kansas will have access to 4 Ascension hospitals and close to 100 providers. 
• Members who live in Tennessee will have access to 8 Ascension hospitals and over 1,500 providers. 
• Members who live in Texas will have access to 9 Ascension hospitals and over 4,000 providers. 

Deductible

A deductible is the amount you pay for healthcare services before your health insurance begins to pay.

Example: You have a $1,000 deductible. You will pay all of your healthcare expenses up to $1,000. Once you reach $1,000, you will share the cost of your plan by paying coinsurance.

Coinsurance

Coinsurance is the amount you pay after you reach your deductible. Your insurance will pay a portion of the medical bill, and you will be responsible for the rest.

Example: You receive a medical bill of $500. Now that you have reached your deductible, your insurance states they will pay 80% of the bill and you will pay 20%. The insurance is now responsible for $400, and you are responsible for $100.

Copay

A copay is a flat fee that you pay when you visit the doctor. It is a set amount of money you pay for a covered service. Copay amounts are often listed on your ID card. Your insurance will determine the amount of copay for each service.

Example: You need to visit your PCP. You have a copay of $25. When you check in and present your insurance, you will be asked to provide a payment of $25 to see the doctor.

Premium

A premium is the amount you pay monthly to have health insurance coverage. In addition to your premium, you may have to pay a deductible, copayment and/or coinsurance. You may qualify for a subsidy that will lower the cost of your premium through the Affordable Care Act.

An out-of-pocket maximum is the most amount of money you will have to pay during the plan year. Once this out-of-pocket maximum is met, the health insurance plan will cover everything at 100%.

Example: You have a health plan with a $1,000 deductible, 20% coinsurance and $2,500 out-of-pocket maximum. You have surgery at the beginning of the year and receive bills for $1,000. You pay these bills which apply to your deductible and your out-of-pocket expenses. You continue to receive bills and pay 20% of those bills until you reach $1,500. You have now paid $2,500 in out-of-pocket expenses, and your health plan will begin to pay 100% of covered costs for the rest of the plan year.

A plan year is the 12 months between the date your benefits coverage is effective (begins) and the date your coverage ends.

Example: Your coverage begins on January 1 and ends December 31.

In-network doctors are contracted with an insurance plan to offer a discounted rate. Out-of-networks doctors have not agreed to the discounted rate. No payments will be made to an out-of-network doctor or facility through Ascension Personalized Care unless it is an emergency.

Example: You see an in-network doctor that charges $500. A discount is applied because of the negotiated rate. The discount is $50. Your health plan will pay $400. You’ll pay the remainder, which is $50.

A deductible is the amount you pay for healthcare services before your health insurance begins to pay. Normally, a higher deductible will mean a lower premium (amount you pay each month). If you pay a higher premium, your deductible will most likely be lower and your health insurance will begin to pay sooner.

Essential health benefits (EHB) are a set of 10 service categories that each health plan must cover under the Affordable Care Act. These 10 essential health benefits are:

1.  Ambulatory patient services (also known as outpatient care. This includes any services you can get without staying in the hospital.)
2.  Emergency services
3.  Hospitalization
4.  Pregnancy, maternity, and newborn care
5.  Mental health and substance use disorder services, including behavioral health treatment
6.  Prescription drugs
7.  Rehabilitative and habilitative services and devices
8.  Laboratory services
9.  Preventive and wellness services and chronic disease management
10.  Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

A summary of benefits and coverage (SBC) is a document that shows deductible and copay information as well as everything that is covered under the plan. This document is used to compare health plans.