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terms you should know

Below are some common terms used throughout this guide Out-of-Pocket limit. The out-of-pocket limit refers to the
that you should know. specified dollar amount of coinsurance incurred for covered
services and covered medications in a benefit period. When
Coinsurance. The percentage of costs of a covered health the specified dollar amount is reached, Highmark begins to
care service you pay (e.g., 10%, 20%, 30%, etc.) after you have pay 100% of all covered expenses. See your Summary of
met your plan deductible. Benefits for the out-of-pocket limit. The out-of-pocket limit
does not include deductibles and amounts in excess of the
Balance Billing. An out-of-network provider’s billing for plan allowance.
charges above the amount reimbursed by the health plan (i.e.,
the difference between billed charges and the amount paid). family out-of-Pocket limit. The family out-of-pocket
limit refers to the amount of coinsurance incurred by you
copayment (or copay). A cost-sharing arrangement in or your covered family members for covered services and
which you pay a flat fee for a specified service. For example, covered medications received in a benefit period.
$15 for a primary care physician office visit.
Once all covered family members have incurred an amount
equal to the family out-of-pocket limit, claims received
deductible. The amount you pay for covered health care by Highmark for all covered family members during the
services before your insurance plan starts to pay. For example, remainder of the benefit period will be payable at 100% of the
with a $250 deductible, you pay the first $250 of covered plan allowance for covered services or 100% of the provider’s
services yourself.
allowable price for covered medications.
After you pay your deductible, you usually pay only The dollar amount specified shall not include any amounts paid
coinsurance (e.g., 10%) for covered services. Your insurance for deductibles or amounts in excess of the plan allowance.
company pays the rest.
In the case of family coverage, benefits for any individual
Emergency. A serious medical condition resulting from covered family member will not be payable at 100% until the
injury, sickness or mental illness, which arises suddenly and entire family out-of-pocket limit has been satisfied.
requires immediate care and treatment — generally within 24
hours of onset — to avoid jeopardy to life or health. Total maximum Out-of-Pocket. The total maximum out-
of-pocket, as mandated by the federal government, refers
provider Network. A group of health care providers who to the specified dollar amount of deductible, coinsurance
have contracted with a PPO to provide care at a discounted incurred for network covered services and covered
rate. medications and any qualified medical expenses in a benefit
period. When the specified individual dollar amount is attained
A health plan’s network includes health care providers such by you, or the specified family dollar amount is attained by
as primary care and specialty physicians, labs, x-ray facilities, you or your covered family members, Highmark begins to pay
home health care companies, hospice, medical equipment 100% of all covered expenses and no additional coinsurance
providers, infusion centers, chiropractors, podiatrists, and and deductible will be incurred for network covered services
same-day surgery centers.
and covered medications in that benefit period. See your
Summary of Benefits for the total maximum out-of-pocket. The
total maximum out-of-pocket does not include out-of-network
cost-sharing, amounts in excess of the plan allowance.

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