We know health insurance terms can be a bit confusing, so we’ve created this guide to help you understand the basics and feel more confident about the process! Read on to learn about common insurance terms and how they may apply to your insurance plan.
Insurance terms related to your coverage
-
In-Network Provider: When a healthcare provider has an agreement with your insurance company to offer services at a discounted rate.
- When Talkspace verifies your coverage, we check if we’re in- or out-of-network under your health plan.
- Out-of-Network Provider: When a healthcare provider does not have an agreement with your insurance company. Because of this, your insurance may cover less of the cost, and you might have to pay more.
- Covered Service: A healthcare service or treatment included in your insurance plan's benefits, such as preventive care, doctor visits, hospital stays, surgeries, prescription drugs, mental health services, diagnostic tests, and emergency care. While your insurance plan helps pay for these services, they’re not always fully covered. You may still have to pay some out-of-pocket costs, like copayments, deductibles, coinsurance.
- Non-Covered Services: A healthcare service or treatment not included in your insurance plan’s benefits. You will be responsible for the full cost of a non-covered service.
Insurance billing terms
- Deductible: The amount you must pay out-of-pocket for covered services before your insurance starts covering expenses. If you haven’t met your deductible yet, you’ll be responsible for the full cost of the services until you do.
- Copay: A fixed amount you pay for a covered healthcare service, usually at the time of service. Depending on your plan, a copay can apply before and after you reach your deductible.
- Co-insurance: A percentage of costs for a covered service you’re responsible for after you meet your deductible. For example, if your co-insurance is 20%, you will pay 20% of the covered service costs while your insurance covers the remaining 80%.
- Out-of-pocket maximum (or out-of-pocket limit): The most you’ll pay out of pocket in an insurance policy year. Once you reach your maximum, your insurance pays 100% of all covered services for the remainder of the year. Payments like deductibles, copayments, and coinsurance count toward this limit, but premiums and payments for non-covered services don’t.
- Claim: A request for payment submitted by you or your healthcare provider (like Talkspace) to your health insurer for services you’ve received. Claims provide insurers with information on the care rendered and by who by including information like CPT and diagnosis codes, rendering provider, TIN and NPI.
- Explanation of Benefits (EOB): A document from your health insurer detailing the services that were covered and breaking down the costs, such as the total amount billed by Talkspace, the amount your insurer covered, and the remaining balance you’re responsible for.
Understand how these insurance terms may apply to your health plan
To understand how these terms apply to you, we recommend reviewing your insurance plan documents for the following:
- The services and treatments covered under your plan.
- Your deductible and out-of-pocket maximum amount.
- What your copay amounts and coinsurance percentages are, and when they apply with regards to your deductible.
If you’d like to know your specific out-of-pocket costs for Talkspace services, please contact your health plan provider. Talkspace does not have access to your individual insurance plan details and cannot confirm your final costs before a claim is processed.
For more information on how the billing process works at Talkspace, check out Talkspace Billing: How it Works.