Faqs

A deductible is the amount of money you must meet before your plan begins paying for services covered by coinsurance. Some services, such as office visits that require copays do not apply to the deductible. For example, if your plan’s deductible is $3,000, you’ll pay 100 percent of eligible healthcare expenses until you have met the $3,000 deductible. After that, you share the cost with your plan by paying coinsurance.

Your share of the costs of a covered health care service, calculated as a percentage of the allowed amount. You pay coinsurance after you have met your deductibles. For example, if the coinsurance percentage is 30% and the plan’s allowed amount for an office visit is $100. Once you’ve met your deductible, your coinsurance payment of 30% would be $30. The health insurance plan pays the rest of the allowed amount.

A copay is a fixed or flat dollar amount you must pay each time you visit the doctor or purchase medicine. This amount will vary depending on where you go for care, the type of doctor you see and the kind of medicine you need. Not all plans have copays.

This is the most you could pay in deductible, copay and coinsurance in a year. Once the maximum-out-of-pocket limit is reached, the plan covers 100% of all eligible expenses.

An E OB is a statement that comes in the mail and explains details about a submitted insurance claim. The E OB shows the portion that was paid by the insurance carrier and what payment, if any, will be the patient’s responsibility. Even though it resembles a bill, it is not. The bill for your portion will come from the health care provider and should be paid to the provider.

In general, a preventive care visit is one where you are going for a general checkup and don’t have a specific concern. If you have a specific ailment for the doctor to check on, this is typically considered a diagnostic visit. Be aware, however, if you go to the doctor for a yearly check-up and bring up ailments to the doctor, part of the visit might be billed as preventive and part as diagnostic.

It depends. Different plans have different networks of providers, and you should check with your doctor to confirm they work with the new carrier and plan. This is an important consideration, because in-network providers are less costly than out-of-network providers. And some plans don’t have any out-of-network coverage, which means you’d be responsible for 100% of the cost of services provided at a doctor that’s out-of-network.

COBRA: The Consolidated Omnibus Budget Reconciliation - Act provides a temporary continuation of group health coverage that would otherwise be lost due to certain life events.

A group of doctors, clinics, hospitals, and other healthcare providers that have an agreement with your medical plan provider. You pay a negotiated rate for services when you use in-network providers.

Care received from a doctor, hospital, or other providers that are not part of the plan agreement. You will pay more when you use out-of-network providers since they don’t have a negotiated rate with your plan provider. You may also be billed the difference between what the outof-network provider charges for services and what the plan provider pays for those services.

A premium is an amount you and your employer pay each month in exchange for insurance coverage.