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Provider: A clinic, hospital, doctor, lab, health care practitioner, or pharmacy.
Insurer or carrier: The insurance company providing coverage to the policy holder.
Policy holder: The individual or business (“group”) that has entered a contractual relationship with the insurance company.
Insured: The person with the health insurance coverage. For individual health insurance, you may be both the policy holder and the insured.
Premium: The amount of money charged by an insurance company for coverage. The cost of premiums may be determined by several factors, including age, geographic area, number of dependents and tobacco consumption. Policy holders pay these rates annually or in smaller payments over the course of the year, and the amount may change over time. When insurance premiums are not paid, the policy is typically considered void, and companies will not honor claims against it. Self-employed persons may deduct the cost of their individual health insurance premiums from their taxes.
Copayment (Copays): A fixed amount you pay for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
Deductible: The amount you owe for health care services each year before the insurance company begins to pay. For example, if your annual deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services that are subject to the deductible. The deductible may not apply to all services, such as preventive care services.
Deductibles are useful for keeping the cost of insurance low. The amount varies by plan, with lower deductibles generally associated with higher premiums. They are standard on most types of health coverage.
Coinsurance: Your share of the costs of a covered health care service calculated as a percent (for example, 20 percent) of the allowed amount for the service. You pay coinsurance plus any deductibles you still owe for a covered health service.
Out-of-Pocket Maximum: The most you will be required to pay for your health care during a year, excluding the monthly premium. It protects you from very high medical expenses. After you reach the annual out-of-pocket maximum, your health insurance or plan begins to pay 100 percent of the allowed amount for covered health care services or items for the rest of the year. Copays, deductibles, and coinsurance count towards the out-of-pocket maximum.
Preventive Care: Medical tests and checkups, immunizations, and counseling services used to prevent chronic illness from occurring.
Every reasonable effort has been made for the information provided to be accurate. It is intended to provide an overview of the coverage’s offered. It is in no way a guarantee or offer of coverage. Each carrier has the ability to underwrite based on its contract. Each carrier’s contract, underwriting, and policies will supersede the information on this page. Please be aware that each carrier may have exclusions or limitations and you must consult your summary plan description and/or policies for details.