Health Insurance BasicsHealth insurance protects you from financial losses due to illness or injury. In exchange for your payments, known as premiums, your insurance company promises to pay for some or all of your health care services. Show
Health Insurance Terms
Difference Between Co-Insurance and DeductibleIf your health insurance company says a covered benefit “applies to deductible and co-insurance,” you must pay the amount of your deductible. Your deductible is a declining balance. You must pay the amount of your deductible before your insurance company begins to reimburse you for medical expenses. After you have paid your deductible, then you only need to pay co-insurance, or a portion of your medical expenses. Your health insurance company pays the rest. Under most health insurance plans, there is a limit to the amount of co-insurance you have to pay. This is known as an “out-of-pocket maximum.” In general, you pay your deductible and co-insurance directly to the doctor’s office, not to the insurance company. Co-Pays or Co-PaymentsYou pay a co-pay (or co-payment) at the doctor’s office. A co-payment is a fixed amount of money that you pay when the doctor delivers (or renders) services to you. Co-pays DO NOT count toward your deductible or co-insurance. Depending on your insurance policy and on the kind of doctor you see, the amount of your co-pay may not always be the same. For example, you might pay a $20 co-pay to see a Family Practitioner, but you might pay a $50 co-pay to see a specialist, such as an Oncologist. In general, if the doctor’s title has “ist” at the end, the doctor is a specialist and not a primary care doctor. Example In-Network Claim Under UNC System Health Insurance Plan (Deductible Not Yet Met)If you have not yet met your deductible, the example below illustrates how your claim might break down. The dollar amounts in this example are for illustrative purposes only. Actual dollar amounts will vary depending on the service(s) you receive and the provider(s) you see:
Explanation of Above ClaimBecause you pay a co-pay at your doctor’s office visit, your co-pay is deducted first: $250-$20 = $230. Next, your deductible applies: $230-$200 = $30. Your co-insurance applies next. You are responsible for 20% of $30, or $6. Your insurance company is responsible for 80% of $30, or $24. Therefore your total responsibility is $20 + $200 + $6 or $226. Example In-Network Claim Under UNC System Health Insurance Plan (Deductible Met)If you have met your deductible, the example below illustrates how your claim might break down. The dollar amounts in this example are for illustrative purposes only. Actual dollar amounts will vary depending on the service(s) you receive and the provider(s) you see:
Explanation of Above ClaimBecause you pay a co-pay at your doctor’s office visit, your co-pay is deducted first: $250-$20 = $230. Because you have met your deductible, your remaining balance is $230. Your co-insurance applies next. You are responsible for 20% of $230, or $46. Your insurance company is responsible for 80% of $230, or $184. Therefore your total responsibility is $20 + $46 or $66. Example Out-of-Network Claim Under UNC System Health Insurance Plan (Deductible Not Yet Met)If you have not yet met your deductible, the example below illustrates how your claim might break down. The dollar amounts in this example are for illustrative purposes only. Actual dollar amounts will vary depending on the service(s) you receive and the provider(s) you see:
Explanation of Above ClaimBecause you pay a co-pay at your doctor’s office visit, your co-pay is deducted first: $250-$20 = $230. Next, your deductible applies: $230-$200 = $30. Your co-insurance applies next. You are responsible for 30% of $30, or $9. Your insurance company is responsible for 70% of $30, or $21. Therefore your total responsibility is $20 + $200 + $9 or $229, but you may owe more money if the doctor charges more for a service than the insurance company allows. Example Out-of-Network Claim Under University-sponsored Health Insurance Plan (Deductible Met)If you have met your deductible, the example below illustrates how your claim might break down. The dollar amounts in this example are for illustrative purposes only. Actual dollar amounts will vary depending on the service(s) you receive and the provider(s) you see:
Explanation of Above ClaimBecause you pay a co-pay at your doctor’s office visit, your co-pay is deducted first: $250-$20 = $230. Because you have met your deductible, your remaining balance is $230. Your co-insurance applies next. You are responsible for 30% of $230, or $69. Your insurance company is responsible for 70% of $230, or $161. Therefore your total responsibility is $20 + $69 or $89. Please contact the Student Health Insurance Office if you have any questions at: or 919-515-2563. What are networks in insurance?A health insurance network is a group of doctors and medical care providers across multiple specialties that have a contract to provide health care services to members of a health insurance plan.
What does Ona mean for health insurance?Other Needs Assistance (ONA) falls under FEMA's Individuals and Households Program and provides financial help after a disaster to cover necessary expenses and serious needs not paid by insurance or other sources. These needs may include transportation, childcare and medical and dental expenses.
What does IPA stand for in healthcare?Independent Practice Association (IPA) — a type of health maintenance organization (HMO) in which individual practitioners see patients enrolled in the HMO but also treat their own patients who are not HMO participants. Compensation to the physician is based on either a per-patient fee or a discounted fee schedule.
What is group ID on insurance card?Member ID Number: identifies you, the insured. Group number: Identifies your employer plan. Each employer choses a package for their employees based on price, or types of coverage. This is identified through the group number.
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