A fixed amount ($20, for example) you pay for a covered health care service.
The amount you owe for covered health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 for covered services. Some plans pay for certain health care services before you’ve met your deductible.
The amount the insurance company pays for a dental claim, up to the annual maximum.
Under a Health Maintenance Organization (HMO) plan members choose a primary care physician (PCP) from in-network providers. Their PCP will then oversee all healthcare-related services, including referrals and authorizations. HMOs are ideal for employees who would like one doctor to coordinate all their medical care at predictable costs.
Under the Health Savings Account (HSA) medical plan, when obtaining care, you will pay the contracted rate for covered services until you reach a set amount known as your deductible. After you reach your deductible, you’ll start paying less – just a copay or a percentage of the charges (coinsurance) for the rest of the year, or until you reach your out-of-pocket maximum. Members of this plan are entitled to open up a Health Savings Account (HSA) to set aside funds to help pay for services rendered on this plan.
An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates. An out-of-network provider is not contracted with the health insurance plan.
The amount you are required to pay for a medical claim, apart from any co-payments or deductibles.
This phrase usually refers to physicians, hospitals or other health care providers who are considered non-participants in an insurance plan (usually an HMO or PPO).
This the most you’ll have to pay during a policy period (usually a calendar year) for health care services. Once you’ve reached your out-of-pocket maximum, your plan begins to pay 100 percent of the allowed amount for covered services (in-network).
Primary Care Physicians (PCP) are the gatekeepers to your health care. They direct you to specialists for consultation or special care, order lab tests, and other services you may need. HMO plans are PCP directed.
Preferred Provider Organization (PPO) plans are health care plans contracted with a network of medical providers. PPO members have the option to select a preferred provider and only pay their deductible and office visit copay, or select an out-of-network provider and pay a slightly higher amount. PPO members also do not need to choose a primary care physician (PCP) and do not require referrals when going to a specialist.
A drug that has a trade name and is protected by a patent (can be produced and sold only by the company holding the patent).
A generic drug is a chemically equivalent, lower-cost version of a brand-name drug. A brand-name drug and its generic version must have the same active ingredient, dosage, safety, strength, usage directions, quality, performance and intended use as the brand-name drug.
Non-formulary drugs are not on the insurance policy’s list of preferred drugs. Therefore, non-formulary drugs will cost the members more money than formularies (Generic and Brand).
Routine health care that includes checkups, patient counseling, and screenings to prevent illness, disease and other health-related problems.
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Disclaimer: This presentation is to provide a summary of WRNS Studio's employee benefits program. Should any discrepancy arise, please refer to actual plan documents that supersede this presentation. Once enrolled, you will receive a Combined Evidence of Coverage and Disclosure Form that explains the exclusions and limitations, as well as the full range of covered services of your plan, in detail.