The price your plan determines is appropriate for care. When you see out-of-network doctors, your plan’s benefits will be based on this allowed amount.
The difference between what a doctor charges for a service and the allowed amount that your plan covers for this service. You are responsible for this amount.
A provider or insurance company.
A varying amount that you pay when you receive care, and is calculated as a percentage of the allowed amount for a service.
How this works with your deductible: Typically, coinsurance doesn’t kick in until you’ve met your deductible.
For example: Once your deductible has been met, a plan with 20% coinsurance for every in-network specialist visit, means you will owe $20 if a visit costs $100.
A fixed amount that you pay when you receive care.
How this works with your deductible: Typically, you don’t need to meet your deductible for the copay amount to apply, and the money spent on copays doesn’t count toward your deductible.
For example: If your plan has a $20 copay for every in-network specialist visit, you will owe $20 when you go in—period.
A yearly dollar amount that you must pay before the plan pays any benefits.
In-Network vs. Out-of-Network
Every procedure and visit to a doctor costs something.
With an in-network doctor, the health insurance carrier has pre-negotiated how much a service or procedure should cost. This is called an “in-network rate.”
With an out-of-network doctor, because your insurance carrier does not have negotiated rates, you might be charged more for the same services and care. Your plan will probably require you to pay a larger portion of the cost.
A network is made up of the providers (doctors) and suppliers your health insurer has contracted with to provide health care services at negotiated rates.
A physician, health care professional, or health care facility.
High-Deductible Health Plan (HDHP)
HDHP plans are similar to PPO plans, however deductibles are typically higher and monthly premiums are lower. When enrolling in a HDHP, you are able to open and contribute to a Health Savings Account (HSA).
Health Maintenance Organization (HMO)
With HMOs, your primary care physician (PCP) is the gatekeeper to other types of care. If you need to see a specialist, your PCP will be your advocate and refer you to one. Note that HMOs typically do not cover out-of-network benefits.
Health Reimbursement Account (HRA)
Employer-funded account that reimburses employees for incurred medical expenses. Reimbursement dollars received by the employee are generally tax free.
Health Savings Account (HSA)
A savings account that allows you to pay for qualified medical expenses with tax-advantaged dollars. You and/or your employer contribute money to an HSA through pre-tax contributions. The money contributed to the account is not subject to federal income tax at the time of deposit.
The most you’ll pay for care during your plan year before your health insurance begins to pay 100 percent of any allowed amounts.
It’s important to note that this amount does NOT include your premium, balance-billed charges, or healthcare services your plan doesn’t cover.
Preferred Provider Organization (PPO)
Allows you to choose which provider you want to see without going through a primary care physician (PCP). This allows for more flexibility with care and allows you to see a provider in or out of the plans network.
The insurance company may require you to get permission before providing certain services. In these cases, your doctor and insurance will work together to determine whether the services are medically necessary (and whether or not your insurance will cover it). If you’re out-of-network, sometimes you’ll need to help your doctor with this process.