Just like auto insurance covers your car and home insurance covers your home, there are different types of insurances for your care.

• Dental insurance covers your teeth, gums, and oral health, such as dental cleanings.
• Vision insurance will cover your eyes, and that usually includes glasses, contacts, and/or annual eye visits. Sometimes, your vision care is coupled with your health insurance.
• Health insurance covers your medical needs, such as clinic visits, prescriptions, hospital stays, and emergency care.

It is important to know the names of your insurance providers. Your care team will ask for your insurance and will want to make a copy of your insurance cards to keep in your chart.

When it comes to health insurance, there are two types:

• Public insurance are publicly funded insurance plans that come from the government, such as Medicaid and Medicare.
• Private insurance is funded insurance and is a plan that comes from your employer or through the insurance marketplace HealthCare.gov.
  • Healthcare.gov allows you to shop for private and public insurance plans if you are no longer covered by your parent’s insurance and you do not have access to insurance through your employment.

Private or public, your health insurance will have specific procedures, medications, providers, locations, etc. that are covered or not covered under your insurance plan. If possible, it’s important to know what’s covered in advanced of your care needs.

Here are some terms you will hear when figuring out what care is covered by your health insurance.

• In-network: In-network are the providers, clinics, and hospitals that your insurance company is contracted with—this means they are likely covered under your insurance plan.

  Tip: Call your insurance company and ask for a list of in-network providers and locations. Or visit your insurance company’s online website where this list should be kept up to date. It’s common for an insurance company to cover one provider at one location, but not at another. It's important to understand where and who you can see for your care.

• Out-of-network: Out-of-network are providers, clinics, and hospitals that are not covered under your insurance. This means you may have to pay more to see them or visit these locations.
• Prior authorization: Prior authorization is a special approval from your health insurance before you get a treatment, test, or fill a prescription. In some cases, your insurance may not cover the cost if you don’t have a prior authorization.

To receive health insurance, you (or your parents) likely pay monthly, this is known as a premium. The amount you pay depends on your plan. In the United States, your health insurance will work with you and the provider/clinic to cover costs. Some costs you will pay for at your providers office, and others costs will be billed to your insurance company first. Here are some payment types you will hear about:

• Deductible: A deductible is the amount of money you pay before your insurance covers the rest of the costs. This is separate from your premium (monthly payments).
• Co-pay: Also known as a co-payment, is a set fee for a clinic visit or prescription. You typically pay it at your appointment or when you pick up a prescription.
• Out of pocket maximum: Out of pocket maximum is the maximum amount you will pay for on deductibles, copays, and coinsurances for in-network services. After you spend this amount, your health plan pays 100% of the costs for covered benefits.
• Co-insurance: Co-insurance is the percentage of a medical bill that you pay. The rest is paid by your insurance.

Each time you use your health insurance, they will send you an explanation of benefits (either by mail or electronically). The explanation of benefits is not a bill, but rather a statement that tells you what services your insurance covered.

In addition to the terms above, you will also hear your insurance company or provider offices use language and words that define your type of coverage. Below, we’ve explained some of these extra terms that will help you become an expert in understanding your insurance coverage.

• Annual limits: Annual limits are the caps on benefits that your insurance company will pay in a year while you are enrolled in their plan. These caps are sometimes placed on services, such as the number of days you are hospitalized or the number of therapy appointments that are covered.
• Claim: An insurance claim is the request(s) that you make to your insurance company to pay for services covered under your plan. Sometimes, this is also done as reimbursement for costs you’ve already paid.
• Appeal: If your insurance refuses to pay a claim or ends your coverage, you have the right to appeal their decision and have it reviewed. Your insurance may still refuse the appeal or decide to cover what was appealed.
• Denial: A denial is when your insurance company refuses to pay or denies responsibility to pay for medical services for you or a family member.
• Excluded services: Are services that your insurance does not pay for or are not covered.
• Benefit list: Is a list of services that your insurance does pay for or are covered.
• Preventive care: Preventive care is routine healthcare that includes screening and check-ups to prevent illnesses, diseases, or other health problem. Most insurances will cover preventive care and encourage your routine annual visits.
• HSA and FSA: Health savings account (HSA) and flexible spending account (FSA) are usually offered through your insurance company and let you set money aside to help pay for healthcare costs.

When working with your insurances and your providers, we want you to receive your best your care possible. Some of the following terms might come up to help you access the care you need with your insurance plan.

• Generic medications: Generic medicine tends to cost less than the same name brand medicine, even though it is made with the exact same active ingredients. Some insurance companies will only pay for the generic version of a medicine.
• Formulary medications: Is a list of medicines that are covered by your insurance plan. You can call your insurance company to find out if the medicine your provider wants to order is on the list.
• Specialty Pharmacy: Some medicines are not available from local pharmacies because they are used to treat rare conditions or require special handling by a pharmacist. For these, you will need to go a specialty pharmacy. You can call your insurance company to get a list of specialty pharmacies that are covered by your insurance.
• Referral: Some specialist care providers or medical tests require a referral for it to be covered under your insurance plan. Your primary care provider can help you get referrals to the specialists you need to see.
• Order: Most medical tests or labs need an ‘order’ from your provider before you can go and get them done. Your provider will put an order into your chart or give you a paper copy to take with you. Sometimes your provider will ask you about the location you want to go before placing the order.
• Refill: Your medications and medical supplies must be ordered by a provider for you to pick them up or have them delivered. That order may contain more than one refill which would allow you to get more of the medication or medical supply without having to go back to see your provider first. If you do not have any more refills, you must go back to the provider who ordered the medication or medical supply to get a new order. Ask your provider how many refills you have on your medicines or medical supplies.