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Benefits of Joining Health Partners:

Terms to Know

  • Provider: a person or facility that provides healthcare services - doctors, nurse practitioners, hospitals, midwives, surgical centers, and hospital-based doctors. Insurance companies or employers list providers in directories that are supplied to employees. Always check that your provider is a participating provider for your insurance PRIOR to receiving health services.
  • Co-insurance: The percentage of the cost of health services that an employee has to pay under the terms of the health care plan. In most plans, this is shown as “90/10”, or that insurance pays for 90% while you pay 10%. Whether or not you get health services “out-of-area” also effects these percentages. Co-insurance amounts vary from plan to plan. (Compare Co-payment and Deductible; see Out-of-Area Coverage)
  • Co-payment: The dollar amount that you have to pay under the terms of the health plan regardless of the actual charges for the health services given. Thus, you may be obligated to pay $15 for each visit to a physician for typical services you receive. (Compare Co-insurance and Deductible)
  • Deductible: A flat amount that you must pay for health services before the insurance company will pay anything for health care charges. A deductible will be different (usually more) between single and family coverage and can be different for each service rendered, item furnished, or for a period of time, usually a year. (Compare Co-insurance and Co-payment)
  • Out-of-Pocket Expenses: Those costs of health services that you must pay for. Included are deductibles, co-insurance, co-payments, and items and services not covered by insurance (e.g., glasses, contacts, etc.) or which exceed the limits of the coverage.
  • Out-of-Pocket Limit/Maximum: This is the amount you’ll pay during the year before insurance will pay 100% benefits up to the coverage maximum, if any. Until this is met, the employee will pay co-insurance.
  • Out-of-Area Coverage: Benefits for health care provided outside the normal service area of the health plan to which a person seeking medical attention belongs. Such benefits are usually paid for by the plan in emergency circumstances when you’re away from your normal place of residence. Benefits are often lower for out-of-area coverage.
  • Balance Billing: The activity of a provider billing you the excess amount of their charges over the amount covered by insurance, deductibles, co-insurance and co-payments. Providers in your plan have agreed to accept the amount paid by insurance, plus co-insurance and deductibles, as full payment. Balance billing is often prohibited.
  • Drug Formulary: A list of preferred, clinically effective prescription drugs that are covered by insurance. Often on this list are name brands and their generic equivalent. The generic will cost less than the name brand. Covered brand name drugs listed on the formulary have a lower co-pay than covered brand drugs that are not included. Consult your doctor or pharmacist about generic alternatives.
  • Pre-admission Certification (PAC): Also called “pre-certification.” Review and approval for need and appropriateness of the care suggested for you prior to your admission to a hospital or other health facility. This includes outpatient surgery and tests, such as MRIs. Under health plans where PAC is required, preadmission certification is a condition for payment. You’re ultimately responsible for making sure a service is certified prior to admission or the time the health service is provided.
  • Premium: The amount paid for insurance coverage for a specified time. The employee and/or the employer usually pay for the premium for health insurance.
  • Network: The combination of individual and group practitioners, hospitals, clinics, and facilities who have agreed to see employees in the insurance plan, provide care at negotiated rates, and adhere to the policies and procedures of the insurance plan. Please see your provider directory for a complete listing.
  • Explanation of Benefits (EOB): Statement mailed to you explaining how and why a claim was or was not paid. You should save these documents for future reference should there be an issue with claims payment.

 
 
 
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