Page 4 - Covered 6 Employee Benefits 2021-2022

Insurance Terminology

Deductible – the amount you owe for health care services before your health insurance plan begins
to pay. You may choose a higher deductible to lower your monthly premiums.

Out of Pocket Maximum – the most you pay during a policy period before your health insurance
plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-
billed charges or health care your health insurance plan does not cover.

Coinsurance – your share of the costs of a covered health care service, calculated as a percent of
the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example,
if the health insurance plan’s allowed amount for an office visit is $100 and you’ve met your
deductible, your coinsurance payment of 20% would be $20.

Copay – a fixed amount (for example, $15) you pay for a covered health care service, usually when
you receive the service. The amount can vary by the type of covered health care service.

Primary Care Physician (PCP) – a physician who directly provides or coordinates a range of
health care services for a patient. If you enroll in an HMO plan, you must be assigned a PCP.

Health Maintenance Organization (HMO) – a type of health insurance plan that usually limits
coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-
of-network care except in an emergency. An HMO may require you to live or work in its service area
to be eligible for coverage. Most commonly, an HMO operates as follows:

• Your Primary Care Physician (PCP) will be your main point of contact and refer you to specialist(s)
as needed.

• You and any enrolled dependent(s) are not required to see the same PCP.

• You have the flexibility to change your PCP.

• Any non-emergency services rendered out of network without the proper referral from your PCP

will not be covered.

Kaiser Permanente administers the HMO plans, and a summary of covered services is listed on the
following pages. For a complete listing of covered services for each plan, please refer to your
Summary of Benefits and Coverage (SBC).

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