Page 20 - 2022 Benefit Guide Fives Inc

Insurance Terms

Allowed Amount Maximum amount on which payment is based for covered health care services.
This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider
charges more than the allowed amount, you may have to pay the difference.

Balance Billing When a provider bills you for the difference between the provider’s charge and
the plan’s allowed amount. For example, if the provider’s charge is $200 and the allowed amount
is $170, the provider may bill you for the remaining $30. A network or preferred provider may
not balance bill you for covered services.

Co-payment/Copay A fixed amount (for example, $25) you pay for a covered service, usually
when you receive the service. The insurance plan covers the remainder of the charge.

Deductible The amount you owe for a service your insurance or plan covers before the plan
begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve
met your $1000 deductible for covered services subject to the deductible. The deductible may
not apply to all services.

Co-insurance Your share of the costs of a covered
service, calculated as a percent (for example, 20%)
of the allowed amount for the service. You pay co-
insurance plus any deductibles you owe. For
example, if the insurance or plan’s allowed amount
for an office visit is $200 and you’ve met your
deductible, your co-insurance payment of 20%
would be $40. The insurance or plan pays the rest
of the allowed amount.

Network, Preferred Provider or Participating Provider The facilities, providers and suppliers
your plan has contracted with to provide health care, dental or vision services at a discount.
Some services may be covered only if you use a network or contracted provider, facility or
supplier.

Primary Care Physician (PCP) A physician or nurse practitioner that you see for all your primary
health care needs, including your annual health exam.

Out of Network or Non-Preferred Provider A provider who doesn’t have a contract with your
plan to provide services to you. You’ll pay more to see a non-preferred provider. Services are
usually paid for at a lower amount, which means more out of pocket costs for you. For services
under Delta Dental or VSP members may need to pay for services and complete a reimbursement
form.

Out-of-Pocket Limit The most you pay during a plan period (usually a year) before your insurance
or plan begins to pay 100% of the allowed amount. This limit never includes your premium,
balance-billed charges or care your plan doesn’t cover.

Specialist A category of health professionals that specialize in an area of expertise, such as
chiropractic, orthopedic, cardiac, podiatrist, ear/nose, or oncology care.

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