Glossary

The fixed amount, as determined by your insurance plan, you pay for health care services received.  Once the access fee is applied, the remaining service is provided by deductible and coinsurance.  This typically applies to Emergency Room and hospital visits

Your share of the cost of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service, typically after you meet your deductible. For instance, if your plan’s allowed amount for lab test is $100 and you’ve met your deductible (but haven’t yet met your out-of-pocket maximum), your coinsurance payment of 20% would be $20.

The fixed amount, as determined by your insurance plan, you pay for health care services received.  Deductibles do not apply.

The amount you owe for health care services, without a copay, before your health insurance or plan sponsor (employer) begins to pay its portion. For example, if your deductible is $1,000, your plan does not pay anything until you’ve met your $1,000 deductible for covered health care services.

A statement sent by your insurance carrier that explains which procedures and services were provided, how much they cost, what portion of the claim was paid by the plan, and what portion is your liability. In addition, it explains how you can appeal the insurer’s decision. These statements are also posted on the carrier’s website for your review.

A personal health care bank account funded by your tax-free dollars to pay for qualified medical expenses. You must be enrolled in a HDHP to open an HSA. Funds contributed to an HSA roll over from year to year and the account is portable, meaning if you change jobs your account goes with you.

A plan option that provides choice, flexibility and control when it comes to spending money on health care. Preventive care is covered at 100% with in-network providers, there are no copays, and all qualified employee-paid medical expenses count toward your deductible and your out-of-pocket maximum

A group of physicians, hospitals, and other health care providers that have agreed to provide medical services to a health insurance plan’s member at discounted costs.

• In-Network – In-network providers are doctors, hospitals and other providers that contract with your insurance company to provide health care services at discounted rates.
• Out-of-Network – Out-of-network providers are doctors, hospitals and other providers that are not contracted with your insurance company. If you choose an out-of-network doctor, services will not be provided at a discounted rate.  HMO plans do not have out-of-network coverage.

The most you pay during a policy period (usually a 12-month period) before your health insurance or plan begins to pay 100% of the allowed amount. This limit does not include your premium, charges beyond the Reasonable & Customary, or health care your plan doesn’t cover. Check with your health insurance carrier to confirm what payments apply to the out-of-pocket maximum.

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.