A collection of common terms for American international students to see a doctor and medical insurance
Many students are confused about the English terminology used for medical bills and insurance claims when they seek medical treatment in the United States. Here, we have compiled the relevant vocabulary for medical treatment and insurance claims in North America, so that students can better understand the American medical industry and insurance-related knowledge.
Preferred Provider Organization (PPO)
Insurance companies will negotiate with some doctors and medical institutions to obtain preferential medical service prices and provide them to policyholders. These contracted doctors and medical institutions together are the institutions within the network of the PPO plan. In the PPO type of insurance plan, the policyholder can choose to see a doctor within the network with a higher payout ratio or choose to see a doctor outside the network. In addition, the PPO type of insurance plan does not need to see a designated doctor, does not require a referral, and has a higher degree of freedom.
SM Insurance uses the “UnitedHealthcare options PPO” medical network. The insurance provider UnitedHealthcare is the largest insurance company in the United States and has a very wide medical network.
*There are many types of health insurance plans in the United States, such as PPO, HMO, POS, etc. Different insurance plans have different degrees of freedom of choice for medical institutions and doctors, as well as different premiums. Kaiser’s insurance plan, for example, is an HMO type. Insured members must see a doctor in an in-network clinic and need to go through their primary care doctor to be referred to a specialist. POS-type plans, on the other hand, can make claims at out-of-network clinics, but require a referral to contact a specialist.
In-Network (Out-of-network)
In-Network Provider refers to institutions such as doctors and hospitals that cooperate with insurance companies. Before seeing a doctor, it is best to confirm that the doctor or clinic is a doctor in the insurance company’s network, so that the insurance company will pay the best ratio, and everyone will not have to spend so much on paying the bills.
*For finding doctors and medical institutions in the Student Medicover network.
Deductible
The deductible is the amount the policyholder must pay before the insurance company begins to pay. The deductible is generally calculated on an annual basis (Policy Year).
Payout ratio Co-insurance
Refers to the percentage of medical expenses paid by an insurance company. For example, the Coinsurance in the SM Elite plan network is 90%, that is, after paying the deductible, you only need to pay 10% of the medical bills of the institutions in the network, and the insurance company will pay 90% of the bills.
*For the definition of PPO medical network, please refer to the collection of medical insurance terms for international students in the United States compiled by SM Assistant.
Co-pay
Similar to the domestic registration fee, it refers to a certain amount of money that you need to pay each time you see a doctor for certain specific items (doctor’s consultation, prescription drugs, etc.). For example, a doctor’s visit usually requires a copay of $20-$40 per visit.
*Co-pay is not counted in Deductible.
Overall Plan Maximum
The policy maximum is the highest amount an insurance company will pay. Students should pay special attention to the fact that the insurance amount is divided into the maximum compensation amount each time and the maximum compensation amount every year. When purchasing insurance, be sure to know what the maximum amount of each insurance policy is, so that you can have the best protection.
SM Insurance’s Prime and Elite plans have no upper limit of insurance coverage, which not only provides students with the highest protection but also meets the requirements of most schools.
Out-of-Pocket Maximum
The maximum deductible limit refers to the maximum medical expenses paid by the insured in one year within the scope of the policy (SM Elite is US$5,000), and the insurance company will start to pay 100% of the medical expenses for the contents of the policy.
Example: The SM Insurance Elite plan has a deductible of $0, the Co-insurance is 90%, and the maximum deductible is $5000. If the insured spends $60000 for medical treatment, then the insured only needs to pay 0+60000*10%=$6000. Since the deductible exceeds the maximum deductible limit, the policyholder will end up paying only $5,000, and the remaining $1,000 will still be covered by the insurance company.
Preventative Care
Preventive treatment is a concept proposed by the US Centers for Disease Control and Prevention, which includes preventive examinations and vaccines.
*For specific types of preventive vaccines and vaccination methods in the United States, please refer to the following summary:
A complete guide to vaccines for international students in the United States (including preventive vaccines and detailed explanations of common vaccines)
Prescriptions Drug
If students have a cold, allergies, or any disease that requires prescription medication, they need to consult a doctor first and ask for a prescription before they can pick up the medicine. The insured needs to pick up prescription drugs at the pharmacy in the network. Generally, the doctor will directly send your prescription to the pharmacy in the network after consultation.
The Preferred, Prime, and Elite plans of SM Insurance all cover prescription drugs. Students need to pay the corresponding copay or coinsurance according to the compensation ratio of different plans and the level of the drug.
Pre-existing Condition
Many health insurance plans exclude coverage for illness or injury that occurred during the period before the effective period and do not pay out until after the effective period. This is for risk control and to prevent overmedication.
However, all plans of SM Insurance include pre-existing conditions (The basic plan has a waiting period of 12 months), which maximizes the interests of the policyholder.
Pre-existing Condition
The biggest advantage of Urgent Care is that it does not require an appointment and can be seen anytime, and some institutions are open 24 hours a day. Urgent Care handles minor emergencies such as fever, stomach aches, scratches, and more. It is worth noting that in the United States, the emergency room (Emergency Room) is generally only in very critical situations, and the cost of going to ER is very high. And if it’s not a life-threatening situation, it’s common to wait three or four hours.
Emergency Room
Emergency rooms are for patients whose lives are in danger. If students encounter a very critical situation, such as a car accident, please call 911 immediately or go straight to the ER. But if the situation is not very serious, don’t go to the emergency room lightly. In non-life-threatening situations, the wait is usually long and the cost is very expensive. If you suddenly feel unwell, you can go to Urgent Care/Walk-in Clinic, etc.
EOB (Explanation of Benefits)
Many students will receive this EOB in their mailbox and insurance website after they go to the doctor with their insurance card. This is not a bill of payment, but a notice to let students know how much the insurance company has paid for you and the remaining expenses you need to pay.
The following picture teaches you to understand the “complex” EOB.
EOB calculates the deductible:
The above is a collection of commonly used terms for medical treatment and medical insurance for international students in the United States compiled by SM Assistant. I wish every international student good health. Don’t panic if you encounter medical or insurance problems, Student discovers will try their best to provide support and support for international students.
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