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INSURANCE TERMS

In-Network:
An indemnity plan where coverage is provided to participants through a network of selected health care providers (such as hospitals and physicians).

Out-of-Network:
The member may go outside their network but MAY incur larger costs in the form of higher deductibles, higher coinsurance rates, or non-discounted charges from the providers. Some patients may not have a difference in their Network benefits.

Deductible:
A fixed dollar amount during the benefit period - usually a year - that an insured person pays before the insurer starts to make payments for covered medical services. Plans may have both per individual and family deductibles.
♦ Deductibles may differ if services are received from an approved provider or if received from providers not on the approved list.

Co-Insurance:
A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses that was paid, after the deductible amount if any. Once any deductible amount and coinsurance are paid, the insurer is responsible for the rest of the reimbursement for covered benefits up to allowed charges.
♦ Coinsurance rates may differ if services are received from an In-Network or Out-Of-Network Provider.
♦ Co-Insurance rates may differ for different types of services.

Co-Pay:
A form of medical cost sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received. The insurer is responsible for the rest of the reimbursement.
♦ There may be separate co-payments for different services.
♦ Some plans require that a deductible first be met for some specific services before a co-payment applies.

Out Of Pocket Maximum:
The maximum dollar amount a group member is required to pay out of pocket during a year. Until this maximum is met, the plan and group member shares in the cost of covered expenses. After the maximum is reached, the insurance carrier pays all covered expenses, often up to a lifetime maximum.

Maximum Allowed Amount:
The maximum amount payable by the insurer for covered expenses for the insured and each covered dependent while covered under the health plan. Chiropractic is usually a dollar amount or visit amount.

*If you are questioning something on your Explanation of Benefits (EOB) from you insurance company, it is best to call the customer number on the back of your insurance card.