Key Insurance Terms
Commonly used health insurance terms
Health insurers negotiate fees and sign agreements with health care providers and facilities, creating a network of providers. Providers that are part of these agreements are considered in-network for members. Generally speaking, members pay less at these in-network facilities in the form of lower copayments and deductibles.
Providers and facilities that do not have a contract with a health insurer are considered out-of-network. Providers and facilities may be more expensive and may not be covered through the health plan.
This is the maximum amount that you will have to pay under your plan. Any care for covered services you get after you meet your out-of-pocket maximum will be covered 100 percent.
A deductible is the amount you pay before your health plan starts paying for covered services. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of the costs for the services you receive. Once you have paid this amount, your insurance will begin to pay a portion or all of your health care costs up to the out-of-pocket maximum, depending on the plan. If you use a participating provider, your costs are based on our discounted rate.
Some plans require you to pay a percentage of your medical costs, or coinsurance (for example, your plan will pay 80 percent of the cost for services, you will pay 20 percent). If you use a participating provider, your costs are based on our discounted rate.
Also called a copay, it's a set dollar amount you pay for a covered health service. For example, if you have a $15 copay for a doctor's visit, you simply pay $15 and your plan covers the rest.