Key Terms Understand Your Medical Plans
Provider: A provider is a person, doctor, or facility that provides healthcare.
Insurance Carrier: The health insurance company that provides your insurance policy. The terms insurer, carrier, and insurance company are generally used interchangeably.
Insurance Network: A group of doctors, providers and hospitals that have contracted with an insurance carrier. That means they’ve agreed to accept a pre -negotiated rate for medical services or supplies.
In-Network: A provider that has contracted to be a part of your Insurance Network. Seeing an in-network provider for medical services can significantly reduce your medical expenses.
Out-of-Network: A provider that has no contract with your health plan. There are no discounted rates for services and no contracted limits to the amount they can charge you. The general rule is that you will pay more for services if you use out-of-network providers.
Annual Deductible: The amount of money per year that you need to pay for your health care costs (such as doctor’s visits, medication, etc.) The common phrase “meet your deductible” refers to having paid up to that set dollar amount in covered health expenses. The amount varies by plan.
Individual deductible the amount one person needs to meet for coinsurance to kick in. Family deductible is the maximum amount that a family needs to meet for coinsurance to kick in for everyone in the family.
Coinsurance: The percentage of covered health costs you're responsible for paying after you've met your deductible. It's like when friends in a carpool cover a portion of the gas, and you, the driver, also pay a portion.
Copay: A fixed dollar amount you pay for a specific service.
Example: If you have a $20 copay for Primary Care Visits, you will owe a flat fee of $20 for each appointment with a primary care physician.
Out-Of-Pocket Maximum: The most you could pay for covered medical expenses in a year. This amount includes money you spend on deductibles, copays, and coinsurance. Once you reach your annual out-of-pocket maximum, your health plan will pay your *covered medical and prescription costs for the rest of the year.
* Please Note : Out-of- network providers may charge more for “covered medical services” than the maximum amount your Insurance Carrier allows. You will be responsible for paying the difference between the allowed amount and the provider’s bill. This is referred to as “ balance billing .” It is one of the reasons out -of-network coverage is typically more expensive than in-network.
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