Understanding the U.S. Healthcare System | Kent State University

Understanding the U.S. Healthcare System

Medical Terminology

In the U.S., the healthcare system can be more complicated than your home country's healthcare system. Below, we listed the most common terms that are used with insurance companies. It is important to understand your current health insurance plan and know what is and is not covered with your insurance policy.  You can find more information at this website, where insurance is explained in greater detail. Please note: that if you are required to purchase international student health insurance, you will abide by the Kent State University regulations to purchase United Healthcare. plans.

Capped benefits

A capped benefit limits the amount your health insurance will pay in a given situation. For example, an insurance policy may have cover mental health, but only $50 a day. Some plans list this cap on the benefit table while others only list these caps in the policy wording. Be sure to read carefully and look for any limits on coverage.

Exclusions

A list of exclusions is found in every health insurance plan and it is extremely important read each exclusion individually. This list will tell you what is NOT covered – which can even important than the list of benefits in some situations. 

Pre-existing Conditions

To put it simply, a pre-existing condition is any illness or injury you had before your insurance plan started. Some insurance plans exclude pre-existing conditions all together, others have a waiting period, and still others may cover it right away. If your pre-existing condition is not covered then neither are the doctor visits, prescriptions or related treatments.

Maternity

Prenatal, delivery and post-natal care does not come standard on all insurance plans. If you anticipate becoming pregnant, it is important to check if your insurance plan covers maternity and if there is any waiting period that applies. Keep in mind that insurance plans are designed to help protect you financially for future events, so once you become pregnant there are few to no options available to cover the cost.

Organized Sports

If you plan to participate on a sports team as an international student (intercollegiate, intermural, or club) it’s important to make sure those injuries would be covered by your plan. Organized sports can be excluded from coverage all together, or may be a capped benefit – meaning you will only have coverage up to an amount lower than the policy maximum on your plan.

Mental Health

It can be difficult to be away from home for so long and many students seek mental health assistance while they are in the U.S. Even if you don’t think that you will need it, it’s always a good idea to verify ahead of time if mental health is included in your coverage.

Premium

A premium is the initial cost of buying insurance coverage and can be paid as a lump sum or as installments throughout the duration of the policy. If you fail to pay your premium when it is due, your insurance policy will be automatically cancelled. Depending on your insurance carrier, your policy may be restored if you pay the outstanding amount within a certain time period.

Deductible

The deductible is the amount of money you are responsible for paying for medical expenses before the insurance company begins to pay on your behalf. For example: If you choose a plan with a $1,000 deductible, you are responsible for the first $1,000 of your medical bills. After your deductible has been paid your insurance company will begin to pay for all eligible expenses.

Most insurance plans have different deductibles for different types of coverage, for example you might have to meet a $1,000 deductible before your insurance will pay for a hospital visit, but only a $250 deductible before your insurance will pay towards prescription medication. Keep in mind that the higher your deductible, the lower your premiums will be each month, but you will also be responsible to pay more when you seek treatment.

Coinsurance

Coinsurance is a cost sharing agreement between the insurance company and the insured. This means that the insured must pay a certain percentage of his or her medical costs (after the deductible has been paid). These percentages differ from plan to plan so be sure to check the policy wording before choosing a plan.

Copayment

Not to be confused with coinsurance, copayment is the set amount you pay each time a medical service is accessed. Copay fees vary between policies, but are typically $25 or less. Your insurance policy for example, may require you to pay $25 for a doctor’s appointment and $10 per prescription up to a specified coverage limit.

Out-of-pocket Maximum

This is the highest dollar amount that you must pay for covered expenses under your insurance policy, including deductibles and coinsurance. After this dollar amount has been reached, your eligible medical bills will be covered 100%. Generally these maximums are between $1,000 for an individual and up to $11,000 for a family

Provider Network

Provider network (also known as an in-network provider) is a group of medical providers that have contracted with the insurance company to provide health care services. In-network providers typically charge less for the same service compared to non-network providers, so using an in-network provider can save you money and they will usually accept direct payment from your insurance company.

Usual, Reasonable and Customary

Usual, Reasonable and Customary (also known as URC) is the average cost for a particular treatment in a particular geographic area. It is the amount that insurance companies use to describe the limit on how much they will pay for covered expenses. If most providers usually charge $5,000 for a particular procedure in Chicago, the insurance company will not pay a doctor $10,000 for the same procedure. Instead, they will limit their payment amount to "Usual Reasonable and Customary" - in this example, $5,000.

Repatriation of Remains

On most insurance plans, repatriation of remains covers the cost of returning the insured’s body back to their home country in case of death. 

Emergency Medical Evacuation

Emergency Medical Evacuation provides medically necessary transportation to the nearest qualified medical facility, not necessarily your home country.

Beneficiary

This is the person who would receive any insurance benefits in case the policy holder was to pass away while on the insurance plan.