Page 21 - 2022 Fives Landis Corp Benefit Guide

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 $1,000, your plan won’t pay anything until you’ve met your $1,000 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 dis-
count. 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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