BASIC TERMS FOUND IN HEALTH INSURANCE POLICIES
Breast cancer care and treatment expenses can be a heavy burden on you and your family. A survey found that only about 40% of Hong Kong people are prepared for future cancer treatment costs. Patients and families may suffer financial hardships and sometimes even go bankrupt. Many patients have no choice but to give up cancer treatments.1
Luckily, most health insurances in Hong Kong cover cancer medical expenses from diagnosis to post-treatment recovery.2 However, the language of insurance can be confusing. To help you pick plans or make claims, here is a list of basic terms in health insurance you need to learn.
MONTHLY PREMIUM
This is how much you need to pay per month to be insured. You pay this fee monthly, regardless of whether you have made any claims. This is similar to paying for your car insurance even if you never crash your car.3 Monthly premium price is cheapest for the youth, healthy individuals, and non-smokers/drinkers. If you are older or are applying for insurance after diagnosis, you might be charged extra or denied.4
For medical care, you will have to pay some “out-of-pocket (OOP) costs”:
Annual Deductible
This is the fixed amount of money you must pay each year for eligible medical expenses before your insurance policy kicks in.3
Co-insurance
Aka cost-share. This is the percentage you agree to share with the insurance company on your medical expenses AFTER paying your annual deductible. For example, the insurance company covers 80% while you pay for the remaining 20%.3
Co-payment
This is a flat fee for certain medical care services agreed in the policy. For instance, you pay $100 for each visit to a specialist, and the insurance company covers the rest.3
Out-of-Pocket (OOP) Maximum
This is the maximum amount of OOP cost you must pay annually, which is the fixed sum of all deductibles, co-insurance costs and co-payments combined. Premium is not included in the OOP maximum. Once you finish paying the maximum OOP cost, the insurance company must cover 100% of your medical costs for the remaining days of the year. Beware, most insurance companies only count OOP expenses you spend on in-network healthcare providers.3
In-Network vs Out-of-Network
In-network providers are healthcare professionals who agree with your insurance company to serve you at discounted rates. In contrast, you have to pay the regular price for out-of-network healthcare services.5
Allowed Amount
Aka allowable charge. This is a fixed amount of charge that the insurance company deems reasonable for specific healthcare services and is willing to pay for. The allowed amounts for various services change according to the standard rates in your area.5
Prescription Drug Formulary
This is a list of prescription drugs covered by your insurance company. Most formularies are separated into cost levels. Most cancer medications are on the higher cost levels, meaning you will need to pay more OOP costs for them. Still, the prices are lower than when you don’t have insurance coverage.3
