Have you ever looked at an insurance plan document and realized you’d read the entire thing…but didn’t understand any of it? It's hard to make a decision when the vocabulary is the barrier…but it shouldn’t have to be. Here’s an overview of the terms you might see on an insurance plan document and what they mean:

What you pay

• A premium is the monthly amount you pay for your plan, whether you use it or not. 

• A deductible is the amount you’ll pay for care before your insurance company contributes to the cost. If you have a $2,000 deductible, that means you’ll pay $2,000 before your carrier will start to pay. Deductibles reset every plan year and can’t be carried over. 

In many cases, the higher your deductible is, the lower your premium is. That means you might end up paying less monthly, but you’ll have to pay more out of pocket for your medical care before insurance will start to contribute. You might choose a higher premium, lower deductible plan if you have regular medical care needs and want insurance to contribute sooner rather than later.

• Coinsurance is the percentage of what you pay for care after you’ve hit your deductible. If the plan pays 80%, you pay for the other 20%.

• A copay is a flat fee that you pay when you visit a doctor. Copays can differ depending on whether you’re seeing a primary care doctor or a specialist. 

• Your out-of-pocket maximum is the most you’ll pay for care in a year when you visit covered, in-network providers. After you hit your out-of-pocket maximum, your plan will pay for the rest. As you might imagine, the out-of-pocket maximum doesn’t include monthly premiums, out-of-network care and anything the plan doesn't cover. Often, fertility care isn’t included as in-network care, so it won’t contribute to your out-of-pocket maximum.

What your insurance plan pays for…and what it doesn’t

• A coverage maximum is the maximum amount the plan will pay for a specific type of care. Plans often set both an annual and a lifetime maximum, so a $50,000 lifetime maximum is the total across the whole policy. You can imagine how quickly you can hit a plan’s lifetime maximum if you’re getting fertility care!

• Exclusions are treatments or procedures that a plan won't pay for at all. 

• A rider is an optional extra benefit attached to a plan, like dental or vision coverage are often attached to a medical plan. Riders have their own rules and caps. If something is covered by a rider, the main plan's summary won't say much about it, because the details live in the rider's own paperwork.

• In-network vs. out-of-network means whether or not a provider has negotiated a deal with your plan. Getting care from an In-network provider costs you less than out-of-network care. Some plans skip networks entirely and allow you to see any licensed provider.

The fine print 

• A waiting period is the time between when coverage starts and when your insurer will cover your claims.

• Pre-authorization is when your insurance needs to sign off on a treatment or medication before they’ll consider covering your claim for it. If your plan requires pre-authorization and you get treatment anyway, your insurance carrier might deny your claim.

• Fully insured vs. self-funded is about who's really behind your employer's plan. In a fully insured plan, your employer buys a policy from an insurance company, and the insurance company pays your medical bills. In a self-funded plan, your employer pays those bills itself, out of its own money, and an insurance company only handles the paperwork.
  
  State laws require insurance to cover certain things, but those laws generally don't apply to self-funded plans. Because 67% of workers with employer health coverage are in a self-funded plan, state requirements might not apply to your plan. Your company’s HR department can tell you whether your company is self-funded or fully insured.

  
  

• Claim and reimbursement describe how the money moves. On a reimbursement model, you pay the provider and get paid back for approved costs; on others, the insurer pays providers directly.

What to know if the plan document you're reading is about fertility care

A few of these words behave differently once fertility is involved, especially when it comes to exclusions.

There’s no federal requirement for health insurance plans to cover fertility care (source), so most women who go through IVF in the US are paying their own way. In most cases, the only exception is if you have a fertility threatening condition, like some cancers.

For plans that do cover fertility, coverage and plan maximums can be based on the total cost or the number of rounds of fertility treatment. One state's maximum could be a $15,000 lifetime maximum and another's could be two IVF cycles.

Here's how Flora works, using the vocabulary we explained above 

• The premium averages around $40, priced on age and health profile at enrollment. 

• The waiting period is twelve months.

• You’ll owe a 10% deductible.

• There's no network, so you can see any licensed fertility provider in the US.

• The coverage maximum is $10,000 a year and $50,000 across the life of the policy, spent on diagnostics, medications, IUI and IVF once a diagnosis is on record.

• Claims run on reimbursement. You’ll pay for costs up front and get reimbursed after you submit receipts to FLORA.

• One exclusion to know about: we don’t cover elective egg freezing, although it's covered when it's part of treatment for a medical condition.

• Because the policy is yours rather than an employer's, none of it changes when your job does.

• Plans are open to women from 20 to 34 and stay in place through 45.

Learn more and apply at heyflora.com.