Using Your Health Coverage - 7/19/2019 Edition

Cover Page

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Using Health Insurance Coverage

You have health insurance coverage. Great news – now you’re covered! But what’s next? You’re probably going to use that coverage to access to health care treatments and services.

The details of your coverage—and how and when you access health care--will determine what your health plan will pay or if a service will be covered – and that will ultimately impact what you pay out of pocket for your health care.

This tool will give you basic information about health insurance and help you better understand how your health plan works so you can make good decisions about your health care. The examples in this tool are general and do not reflect your health insurance plan. See the Glossary for definitions for some of the terms used in this tool.

This tool has information to help you, and here are a few of the things covered in this tool. You will find more information in the sections that follow.

Always carry your insurance card with you. It has basic information about your health coverage

and tells your doctor and other health care providers who is covered. Show it when you check-in at your provider’s office or go to the pharmacy.

Understand how your insurance plan works. The best way to avoid unexpected medical bills is to

understand your health plan and what your costs will be ahead of time. Pay your monthly premiums on time. Your insurance plan may be canceled if you don’t pay on time

and you may not be able to sign up again until next open enrollment period. If you have a problem paying your bill, call the Assister who helped you enroll, your insurance company, or one of the 800 numbers at the bottom of this page.

Managing your care and out of pocket costs. Pick a Primary Care Provider in your insurance

plan’s network. This can be a doctor, nurse, or physician assistant.

Prescription drugs Know what to do in case of an urgent or emergency medical situation. Plan ahead. What you need to do if you have a planned health procedure or a surgery.

You’ll want to be sure the hospital or facility and all health care providers are in your plan’s network so you don’t have to pay more out of pocket. Call your plan to see if the procedure requires prior authorization.

Understand on the key points of your insurance plan, your health, and your health care.

Update your plan if something in your life changes. Life is unpredictable. If you get married,

divorced, have a baby or adopt, your health coverage needs change. Make sure you keep your plan updated on any life changes.

Getting to Know Your Health PlanMy Health Insurance Card

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There are different ways to get health insurance and different types of plans. This tool does not include details about how to use Medicaid [States can customize to identify state Medicaid plan by name], Medicare, or other types of health plans like supplemental policies. See the Health Insurance Resources section to get information and help with Medicaid, Medicare and other types of health plans.

Summary of Benefits and Coverage (SBC)Schedule of Benefits / Outline of CoverageMy Health Insurance CoverageHow You and Your Health Plan Share CostsPick a Primary Care Provider in Your NetworkAvoiding Balance BillingDifferent Kinds of Plan NetworksJob-Based Health PlansGet Your Prescription MedicinesGet the Most out of Your Health PlanWhat to Do in Case of an EmergencyReferrals and Prior AuthorizationsCoordination of BenefitsLife ChangesHow to File a ClaimUnderstanding How your Claims are PaidHealth Insurance Resources

A special thanks to the Maine Health Access Foundation (www.mehaf.org) for information and graphics derived from its original brochure, I Have Health Insurance! Now What?

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Getting to Know Your Health Plan

Maybe you can’t remember the details about your plan – what it covers, what it doesn’t or what your out-of-pocket costs may be.

Don’t worry. You can get that information when you need it. Here is where you can find information about your coverage or get help understanding your benefits.

Check your insurance card. Your insurance card contains some of the most important information you need to access your health coverage. It tells health providers basic information about your coverage and who is covered. Most insurance cards will list toll free phone numbers and website information where you can access the most current information for your health coverage. Make sure you check the back of the card as there is also important information located there.Many health plans will also provide other important telephone numbers on the insurance card. For example, there may be a number you can call if your plan offers advice from a nurse or telehealth services.

Check your health plan’s website. Most health insurers have websites that will let you access the most up-to-date information about your health plan. This information can include documents that will tell you what your plan covers, what doctors and facilities are in your plan’s network, what prescription drugs are covered under your plan’s formulary, what claims have been paid, and how much of your deductible you still need to meet. You usually need to register or create an account to log-in to get the information specific to your health plan.

Check the SBC. Ask your insurance company or employer for a Summary of Benefits and Coverage (called an “SBC”). This is a short list of your benefits and what the deductibles, co-pays and coinsurance amounts (called cost-sharing) are.

Check the policy. Make sure you have a copy of your policy or plan certificate (if you get your health coverage through work).

Your plan information should include a document called a “Schedule of Benefits” or an “Outline of Coverage.” The documents have more information about your costs and benefits. They will also tell you what services or treatments are not covered (called “exclusions”).

Call the health plan. If after looking, you still have questions about your coverage, call your health insurer.

Other Resources. You can also ask your health insurance agent for help, if you buy your health coverage outside of work; or ask your HR Department to explain things, if you get your health coverage through work.

The next few pages will help you find more information about your health plan and your coverage.

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My Health Insurance Card

Your insurance card contains some of the most important information you need to access your health coverage.

It tells health providers basic information about your coverage and who is covered. Expect to be asked for your insurance card anytime you receive a health care service, talk to a health care provider (a doctor, hospital, or facility), or when you talk to your health insurer.

Health plans usually provide 1 or 2 insurance cards. If you haven’t received your card, call your health plan. You may also be able to print a paper copy from your health plan’s website that you can use.

Keep the card with you at all times, but protect your insurance card like you would other sensitive personal and financial information.

When you get your insurance card, check the information on the front of the card. Does the information match what you bought? Is the plan type correct? Does the network name match your expectation? Are the cost sharing amounts correct? Is there is a Primary Care Physician listed – if so, is that correct?

If any of this information is incorrect, call your health insurer immediately to tell them.

Sample Insurance Card

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Member Service: 800-XXX-XXXX

PCP Co-Pay $15.00Specialist Co-Pay $25.00 Emergency Room Co-Pay $75.00Prescription Group # XXXX

Prescription Co-Pay$15.00 Generic$20.00 Name Brand

Member Name: Jane Doe Member Number: XXX-XX-XXX

Group Number: XXXXX-XX

Insurance Company Name

Plan Type

Effective Date

Send claims to:

My Plan, IncP.O. Box XXXXCity, State XXXXX

Member Service: 800-XXX-XXXX

Nurse Advice Line 24/7: 866-XXX-XXXXTelehealth Services: 888-XXX-XXXX

www.myplan.com

FRONT

BACK

Summary of Benefits and Coverage (SBC)

Your identification card will have some information about your coverage and the cost-sharing to help you figure out what your out of pocket costs will be. The “Summary of Benefits & Coverage” or SBC will give you many more specific details about your plan. For example, it will tell you about the deductibles. It will also tell you about what types of services are covered by your health plan and the co-pays or coinsurance that you’ll be responsible for.

You’ll get the “Summary of Benefits & Coverage” when you shop for coverage on your own or through work, or when you renew or change coverage. If you don’t have an SBC, request an SBC from the health insurance company or your employer. Below is what the front page of an SBC looks like.

You can find a sample of an SBC in the Appendix or at https://www.healthcare.gov/health-care-law-protections/summary-of-benefits-and-coverage/.

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Schedule of Benefits / Outline of Coverage

A Schedule of Benefits (if you get your coverage through work) or an Outline of Coverage (if you buy your coverage outside of work) is a list of the various services covered under a health insurance plan, along with what costs you will have to pay for. You get these schedules so you can see which services and treatments are covered and which are not.

Health plans call health care services and treatments that are covered under your plan “benefits.”. These documents tell you what benefits are covered and tell you what costs you will have to pay for each type of health care service covered by your plan. Some treatments and services may require a co-pay or coinsurance. These documents will also tell you what your deductible is and the maximum amount you would have to pay out-of-pocket in a year (after you’ve paid this amount, the health plan starts paysing for 100% of covered services for the rest of the year).

A Schedule or Outline will list various preventative, hospital, diagnostic, therapeutic, and urgent care services, that may be covered. For example, under preventative services, the schedule may list "Adult physical examination (1 exam per calendar year).".

A Schedule or Outline is usually broken down into several sections:

Heading: This is where the basic information about your health coverage is identified – what type of health plan (HMO, POS, EPO, PPO or Indemnity), who the plan is through, the benefit year and the effective date of coverage for the health plan (not when you were covered). You can learn more about the different plan types on page xxxx.

Your Responsibilities: This area identifies the deductible, co-payments, and co-insurance and tells you what the annual out of pocket maximums are. You can learn more about the different types of cost-sharing on page xxxx.

Your Benefits: This area lists the specific common benefits and often what cost-sharing you will be responsible for in terms of the cost-sharing.

Pharmacy: This area identifies the pharmacy benefits under your health plan and the co-payment information. You can learn more about how to utilize your pharmacy benefits on page xxxx.

Dependent Coverage: This section lists which dependents are covered and through what time frame.

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My Health Coverage

In the below area, jot down information about your health plan and cost-sharing from your Identification Card, your Schedule of Benefits/Outline of Coverage, or your SBC.

Then read the next few pages to understand what the different terms mean and how they are calculated.

Deductible: The amount of money you must spend each year on your medical care before your insurance plan starts paying. Insurance may pay for some preventive services, like an annual physical, even if you have not met your deductible. You may have a separate deductible for coverage of prescription drugs.

My Deductible: Family Deductible:

Prescription Drug (Rx) Deductible: [ ] included in the deductible above

[ ] Not included in the deductible above

My Rx Deductible: ______ My Family Rx deductible: __________

Co-Pay: A fixed fee paid directly to the provider when you get medical care (for example, $40 for every primary care visit).

My Co-Pays:Primary Care:

Prescriptions:

Specialist:

Emergency RoomDepartment:

Prescriptions:

Deductible: The amount of money you must spend each year on your medical care before your insurance plan starts paying. Insurance may pay for some preventive services, like an annual physical, even if you have not met your deductible.

My Deductible: Family Deductible:

Coinsurance: A percentage you pay for most medical care even after you meet your deductible (for example, some insurance companies pay 80% of the bill so your coinsurance bill charge would be for 20% of the cost of each service until you reach your Out-of-Pocket Maximum).

My Coinsurance:

Out-of-Pocket Maximum: The most you pay during a policy period before your health insurance or plan pays 100% for covered services. This maximum does not include your monthly premium.

My Out-of-Pocket Maximum: Family Out-of-Pocket Maximum:

Monthly Premium: A fixed amount that you pay each month or with each paycheck for your insurance plan. If you miss payments or pay late, your coverage could be canceled.

My Monthly Premium:

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How You and Your Health Plan Share Costs—Example

Jane’s Plan Deductible: $1,500 | Coinsurance: 20% | Out-of-Pocket Maximum: $5,000 | Co-Pay: $0

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Pick a Primary Care Provider in Your Network

For most people, it makes sense to pick a Primary Care Provider (PCP) from your insurance plan’s network of providers. You will pay the least money out of pocket if you use providers in your health plan’s network. That’s because the health plan has negotiated contracts with the providers.

If you use a provider outside of your health plan’s network, you will pay more. And, some plans don’t pay anything for care with non-network PCPs or specialists.

Your PCP is your “medical home” where you call or visit each time you need medical care. They keep your medical record and help you get services from any specialists or other health professionals that you need.

Providers include a wide variety of health professionals: Doctors, Nurse Practitioners, Mental Health Specialists (also called Behavioral Health Specialists or Counselors), Dentists, and others.

How to Pick a Primary Care Provider in Your Network

To find the names of providers near you who are in your insurance plan’s network, you can:

• Contact your insurance company by phone. This number is on your insurance card.• Look on your health insurance company’s website.• Look in your insurance handbook to see which providers will accept your plan.• Call your provider’s office. Ask them:

1. Do you take my insurance?2. Are you in my plan’s network?

Your insurance company may assign you to a primary care provider (PCP). Usually you can change providers if you don’t like the one they assigned you. Contact your insurance company to find out how.

If you need special treatment, be sure to check whether your local hospital or specialists are part of your plan’s network.

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Avoiding Balance Billing

Balance bills happen when a provider charges more than your insurance company pays and the provider sends you a bill for the difference. Providers that are in your insurance company’s network have agreed to accept the insurance company’s payment as full payment and not to send you a balance bill. So you can avoid balance bills by choosing providers in your insurance company’s network.

Sometimes you may not be able to choose a provider in your insurance company’s network. You may need emergency treatment or an out-of-network provider may provide services to you at an in-network hospital. In these cases, your state may have laws to protect you from balance billing. Contact your state insurance department to find out more.

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Different Kinds of Plan Networks

My plan is: an HMO a PPO an EPO I don’t know

See page xx to learn more about in-network and out-of-network providers.

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Job-Based Health Plans If you are covered under a health plan through your job or a family member’s job, it is likely that the employer has chosen to pay for its share of employees’ and their dependents’ health care costs directly, rather than pay premiums to an insurance company. These are called self-funded health plans. Many large employers, unions, government agencies and school districts have self-funded health plans.

A self-funded health plan means that your employer is financially responsible and pays claims for everyone covered under the health plan. This is different from what is called a fully-insured health plan, where the insurance company is financially responsible for claims and charges a premium for taking on that financial responsibility.

Self-funded health plans utilize third party administrators (TPA) to review and pay claims for the plan. Sometimes, that TPA shares a brand name with a health insurance company. But the employer still gives ALL of the money to pay those claims – not the insurance company.

State insurance departments regulate fully-insured health plans and those plans must follow state insurance laws. Self-funded health plans are regulated by the U.S. Department of Labor, Employee Benefits Security Administration (DOL-EBSA). State insurance laws generally don’t apply to self-funded plans, but they must follow federal law.

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Get Your Prescription Medicines

Health plans help pay the cost of some prescription medicines. You may be able to buy other medicines, but those on your plan’s approved list of drugs, called the “formulary,” usually cost less. Always give your pharmacy your health insurance card. Prescriptions that you pay for will count toward your yearly out-of-pocket maximum.

To find out which prescriptions are covered through your plan:

• Visit your insurance company website or• Call your insurance company directly to find out what is covered.

Levels or categories of prescription drugs:

$ Tier 1—Generic drugs$$ Tier 2—Preferred, brand-name drugs$$$ Tier 3—Non-preferred, brand-name drugs. These are also brand-name drugs, but are “non-preferred,”

which means they may cost you more.$$$$ Tier 4—Some plans use this tier for specialty drugs, while other plans have a separate “specialty” tier.

If the pharmacy says that your plan doesn’t cover your a medicine you’ve already been taking, some insurance companies may provide a one-time refill. Ask your health plan if they offer a one-time refill until you can talk about next steps with your provider.

In addition, you can ask your health insurer to make an exception for you, so you can get a prescription medicine that’s not normally covered by your plan. Your provider must tell your health insurer that you need this drug because:

•All other drugs covered by the plan have not worked or will not work as well as the drug the provider has prescribed, or

•All other drugs covered by your insurance plan have caused or could cause harmful side effects.

It is a good idea to talk with your providers about the best affordable medications for you, based on your plan.

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Get the Most Out of Your Health Plan

Get preventive care to keep you healthy, avoid emergency room visits, and save you money. Many health plans include coverage of Essential Health Benefits to help you stay healthy, including:

• Care for new mothers and babies• Counseling and substance use disorder services• Prescription medicines• Laboratory services• Help in managing diseases like diabetes or high blood pressure• Other preventive and wellness services• Services for kids (for example, vision checks)

Some of these services may be covered before you reach your deductible. Some preventive services are free to you!

Note: All Qualified Health Plans purchased through the Health Insurance Marketplace [State Marketplace Brand] cover the Essential Health Benefits. Some grandfathered plans or employer-

provided plans from outside the Marketplace do not.

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What to Do in Case of an Emergency

Only use an emergency department if you have a real emergency, such as any severe pain, like chest pain or stomach pain.

Urgent care facilities, sometimes called Quick Care, Express Care, or First Care, are a good choice when you need to see a provider quickly, but your life is not in danger. They almost always cost less than going to the emergency department. If your plan has co-pays, your co-pay for urgent care may not be much more than your co-pay for a doctor visit.

Contact your insurance company to ask about in-network urgent care facilities near you.

If you have an emergency or life-threatening situation, call 9-1-1 or go to the nearest emergency department. In an emergency, you should get care from the closest hospital that can help you. Your insurance company can’t require Prior Authorization before going to the emergency department. Your insurance company can’t charge you more for getting emergency care at an out-of-network hospital. You may still have to pay for emergency services, depending on your plan, for instance when your deductible has not been met or through a co-pay.

If you’re not sure what option you need, don’t be afraid to call your primary care provider. They’ll be able to help you decide what is necessary for your situation.

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Referrals and Prior Authorizations

Some health plans, mainly Health Maintenance Organizations (HMOs) require a referral for care from specialists or other providers. A referral is a written order from your primary care doctor for you to see a specialist or get certain medical services. HMOs may require you to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

A broader range of health plans, not just HMOs, may require prior authorization for some services. If you need a special treatment, service, or medical equipment, sometimes you may need to get approval in advance from theyour insurance company. This is called Prior Authorization. Prior Authorization is when your insurance company requires that a decision be made that the service is medically necessary before you receive it. You can ask your provider whether or not you need Prior Authorization.

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Coordination of Benefits

If you are covered by more than one health insurance policy, all of your health plans will work together to pay their shares of your health care costs.

You need to report if you have coverage under more than one health plan to your providers and to your health plan. Coordination of benefit rules determine which health plan is primary (pays first) and which is secondary (pays second).

Your insurance claim will then be processed by one health plan first and the secondary plan’s rules will be applied to any remaining amount. The plans will not pay more than 100% of the treatment cost, so you won’t get double the benefits if you have multiple health plans. And, you will still have to meet any applicable deductibles and pay the cost sharing required by each plan.

But remember, having multiple plans doesn’t mean that everything will be covered. Coordination of benefits will only happen if the medical service or treatment is covered by both health plans. So, if you have cosmetic surgery to improve your looks and neither health plan covers cosmetic surgery, then neither plan will cover those expenses.

Here's an example of how coordination of benefits works: Let's say you visit your doctor and the bill comes to $100. The primary plan picks up its coverage amount. Let's say that's $50. Then, the secondary plan picks up its part of the cost up to 100% -- as long as the services are covered by that insurer and subject to any deductible and cost sharing requirements.

A few examples of coverage under multiple health plans:

You're married and bBoth you and your spouse have separate health plans and you are covered by your spouse’s plan.

A child has coverage through both parents. A child has her own policy (from school or work) and remains on her parent's policy until age 26. A child is married and on his spouse's policy and continues on his parent's policy until age 26. An individual is enrolled in Medicare and a private health insurance plan. A person is enrolled in Medicaid and a health insurance plan. A service member or veteran has TRICARE or coverage through the Veterans Administration (VA) as

well as other health insurance.

If you or a family member have coverage under more than one health plan, talk to both health insurers to learn what is expected of you and how the coverage will be coordinated.

Remember to check both health plans to ensure providers and facilities are in network for both plans if you want to use coverage from both.

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Life Changes – Your Health Coverage Should Too

When life changes occur—a move, a marriage, a job change, or others—health coverage sometimes needs to change, as well. Special rules often apply to making changes to health coverage—this section provides tips on making changes to coverage due to many common life changes.

Many people are covered together with family members in a single health plan. When your family changes, due to marriage, divorce, or the birth or adoption of a child, it’s time to review your health coverage and add or remove members from your plan. You might also make a change to your plan when an adult child reaches age 26 and is no longer eligible to remain on your plan. You can call your health insurance company or visit its website to find out how to add or remove members. Many family changes are qualifying events that allow you or family members to enroll in a plan for the first time, whether through an employer plan or in coverage you buy on your own, and in some cases to change a plan you’re already enrolled in.

Another time when you might need or want to change health coverage is when your job changes. If you lose your job, you may be eligible to continue health coverage you had through the job—if you pay the full premium that you and your employer contributed to. Ask your employer about COBRA continuation coverage. If you can no longer work due to a disability, you may qualify for Medicare after two years.

If your income goes down—whether due to job loss or another reason—it’s a good time to check your eligibility for assistance with health coverage costs. Applying at the Marketplace [State Marketplace Brand] will tell you whether you’re eligible for assistance in purchasing a Marketplace plan or for low- or no-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP) [State Program Names].

A number of other life changes can make you eligible to enroll or change plans through the Marketplace—moving, losing other coverage, changes in citizenship status, and others. You can find out more about special enrollment periods (SEPs) at https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/.

Family changes – Marriage, Divorce, Birth or Adoption of Child, Child aging off of coverage

Job changes – Lose job, FMLA, Disability, change jobs – COBRA, SEP, Medicaid

Retirement/Medicare -

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How to file a claimClaims are usually filed on your behalf by your health care provider. That’s why most offices and hospitals require you to provide your insurance card when you come in for a visit or procedure. Your health care provider will send a bill to your health plan, with information about your condition and how they treated you. Your health plan will compare your coverage with the services billed and pay your health care provider. This payment will not include any amounts that you are responsible for – for example, deductible, copayments or coinsurance. If any part of your claim is not covered, or excluded under your plan, you may be responsible to pay your health care provider.

Some health care providers won’t submit claims for you. So ask when you first see your provider -- AND before you’re billed. If you have to submit your own claim, you need to ask your provider to help you so you have the correct dates, procedures, and codes on the claim form. Keep in mind that when submitting your own claim, most providers will require you to pay the full amount up front. Then, you’ll have to be reimbursed by your health plan.

Understanding how your claims are paid

Don’t pay a bill from your provider or hospital until your health insurer has reviewed the claim.

How do you know when they have reviewed the claim? You will get an “Explanation of Benefits” (EOB) from your health insurer after you visit a provider, clinic, or hospital. It tells what services the insurer paid or did not pay for, and why. If they did not pay for a service you think they should have, you can appeal their decision not to pay.

Your health plan must explain in writing why they denied coverage within a set amount of time. They also must let you know how you can appeal their decisions. If the timeline for the appeals process would seriously put your life at risk, or risk your ability to fully function, you can also file an “expedited” appeal that would get you a quicker decision.

If you need assistance filing an appeal, you can contact [State Insurance Agency] Consumer Assistance Program:

[(800) xxx-xxxx ][TTY: (xxx) xxx-xxxx | State Website]

You can also contact [State Insurance Agency] to file a complaint and start an investigation against an insurance company. The [State Insurance Agency] encourages you to call about any problems you have with a claim denial or service you receive from your insurance company.

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Health Insurance Resources

The Health Insurance Marketplace [State Marrketplace brand] is a resource where individuals, families, and small businesses can learn about their health coverage options; compare health insurance plans based on costs, benefits, and other important features; choose a plan; and enroll in coverage.

1 (800) 318-2596 | TTY: 1 (855) 889-4325 | HealthCare.gov

Your state department of insurance regulates the insurance industry through examining and licensing procedures of insurance companies, licensing producers, reviewing rates and coverage forms, conducting audits, and by sponsoring programs that enhance awareness of and compliance with State laws.

Consumer Assistance Hotline:1 (800) | website | other phone number

For seniors and others enrolled in Medicare, each state operates a State Health Insurance Assistance Program, a free health benefits counseling service for Medicare beneficiaries and their families or caregivers. Find your state’s SHIP at the number below or https://www.shiptacenter.org/.

State Ship Program

Medicare beneficiaries can also contact Medicare directly at the following number:

Medicare800-MEDICARE

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Glossary of Terms

Benefits: The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents.

Claim: A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.

Cost-Sharing: The share of costs for covered benefits that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.

Coordination of Benefits: A way to figure out who pays first when two or more health insurance plans are responsible for paying the same medical claim.

Coinsurance: The percentage of the cost of a covered health care service you pay (20%, for example) after you've paid your deductible.

Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.

If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.

If you haven't met your deductible: You pay the full allowed amount, $100.

Copayments: A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

Let's say your health insurance plan's allowed amount for a doctor's office visit is $100. Your copayment for a doctor visit is $20.

If you've paid your deductible: You pay $20, usually at the time of the visit.

If you haven't met your deductible: You pay $100, the full allowed amount for the visit.

Copayments (sometimes called "copays") can vary within the same plan for different services, like drugs, lab tests, and visits to specialists.

Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services in a year. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services for the remainder of the year. Your insurance company pays the rest.

Exclusions: Health care services that your health insurance or plan doesn’t pay for or cover.

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Network: The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.

Out-of-Pocket Costs: Expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.

Out-of-Pocket Maximum/Limit: The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits.

The out-of-pocket limit doesn't include your monthly premiums. It also doesn't include anything you spend for services your plan doesn't cover.

Primary Care: Health services that cover a range of prevention, wellness, and treatment for common illnesses. Primary care providers include doctors, nurses, nurse practitioners, and physician assistants. They often maintain long-term relationships with you and advise and treat you on a range of health related issues. They may also coordinate your care with specialists.

Prior Authorization: Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

Self-Funded Health Plan: A type of plan usually present in larger companies where the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims. These employers can contract for services such as enrollment, claims processing, and provider networks with a third party administrator, or they can be self-administered.

Urgent Care: Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency department care.

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