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Consumer Assistance HelpLine

1-800-965-7476

Private Insurance

Private health insurance is a contract between you and your insurance company. You pay your monthly premium, and the company agrees to pay part of your medical expenses when you get sick or hurt.

Has your  insurance company denied a claim? For information and help on filing an appeal, check out our guide!

Understanding the”language” of health insurance

The Annual and Lifetime Maximum Benefit Amounts (or Lifetime Cap) are the maximum dollar amounts the plan must pay for all health care services provided to an insured per year (annual) or in his or her lifetime (lifetime cap). If these amounts are exceeded, the insured is responsible for the full cost of services beyond the cap. A combination of Maine and federal law prohibits “total” annual and lifetime limits on most plans. However, certain limits on specific services can be applied in many cases.

The Certificate of Coverage provides detailed contractual information about the benefits covered by the plan. It is important to fully understand this information when evaluating whether the policy covers the health care services you need.

Claims Procedures: This is typically a couple of pages describing the claim filing procedure. The important section here is the part that provides information about how to appeal denials of coverage.

COBRA refers to the Consolidated Omnibus Reconciliation Act which allows employees in certain circumstances to continue, for a limited period of time, health insurance coverage through their employer after they are no longer employed by that employer. It does not apply to all employers.

A Copayment (or co-pay) is a flat fee paid directly to the provider when you receive a medical service (for example, $10 for every visit to the doctor).

Coinsurance is the amount or percentage that you are required to pay for medical care after you have met your deductible. Expression of the co-insurance rate is usually a percentage, for example, if the insurance company pays 80% of the claim, you pay 20%.

Coordination of Benefits is a system used to eliminate duplication of benefits when a person has coverage under more than one health insurance plan.

Covered Benefits: Often separate from the schedule of benefits, this is a listing of what is covered. In some plans, it will be a long list; others will give a short list of a broad range of benefits covered. This section will also give more detail about what and how things are covered.

A Deductible is the amount of money you must spend each year on your medical care expenses before your insurance policy starts paying. Some services under some policies may not be subject to the deductible (for example, preventive services). This means the insurance will cover these services immediately even if you have not met your yearly deductible.

Eligibility: This is an important section in the Certificate of Coverage as it tells when coverage actually begins.

Exclusions and Limitations: This lists the services and procedures that the plan will not cover, such as experimental treatment or cosmetic surgery. It also lists items that have special limits on coverage, such as mental health care, convalescent home care, or treatment for conditions that existed when coverage started, known as pre-existing conditions.

An Explanation of Benefits is a document you get from your insurance company after you receive health care and a claim is submitted to them for payment. The document tells you what claims they paid or did not pay, and why. If they did not pay a claim and you think they should have, you can appeal that denial of payment.

The Insured is the person covered by the health insurance policy.

Maximum Out-of-Pocket is the most money you will be required to pay each year for deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in addition to regular premiums. Once the maximum out-of-pocket amount is paid, the insurance company will pay the full amount for all covered services (as long as you continue to pay the premium).

In-Network and Out-of-Network refers to the provider. In-network providers contract with the health insurance company to provide services to plan members for specific pre-negotiated rates. Out-of-network providers have not contracted with the health insurance plan. You will pay probably pay less if you visit a provider in network than out-of-network.

A Pre-existing Condition is a health problem that existed before the date the insurance became effective. Sometimes pre-existing conditions can be excluded from coverage in certain circumstances.

The Premium is the amount the insured and/or their employer pay in exchange for insurance coverage.

Schedule of Benefits: This is often at the front of the plan. It is the part that details what the insurance company pays and what the employer and employee pay for different categories of service. It lists such things as deductible, co-insurance, and co-pays expected at each doctor’s visit.

Not finding what you are looking for? If you don’t find what you need, or if you have questions about anything in this Guide, please contact us. You can call the HelpLine at 1-800-965-7476 (TTY: 1-877-362-9570) or email us.

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