Insurance FAQ

What is a deductible?

A DEDUCTIBLE is the amount of money you or your dependents must pay toward a health claim before your organization’s health plan makes any payments for health care services rendered. For example, a single plan participant with a $300 deductible would be required to pay the first $300, in total, of claims during a plan year.

What is Co-Insurance?

Co-Insurance is a provision in your health plan that describes the percentage of a medical bill that you must pay and that which your health plan must pay.

What is the difference between Co-Pay and Co-Insurance?

A CO-PAY is the set dollar amount your benefit plan designates for specific services that you seek from a provider. Co-Pay amounts do not apply to your policy’s out-of-pocket maximum to be paid each plan year.

CO-INSURANCE is the percentage that your benefit plan designates you must pay when you receive specific service from a provider over and above the designated co-pay. Most Co-insurance amounts apply to your policy’s out-of-pocket maximums for each plan year.

What is Out-of-Pocket Maximum?

The maximum amount (deductible and co-insurance) that an insured employee will have to pay for covered expenses under the plan. Once the out-of-pocket maximum is reached the plan will cover eligible expenses at 100 percent.

What is an Explanation of Benefits (EOB)?

An EOB shows how your claim was processed in accordance to you benefit plan. The EOB is for your reference to ensure that the amount billed by the provider matches the amount that your insurance carrier says you owe. You may also use an EOB for your flexible spending account reimbursement or for tax purposes.

What is a Pre-Existing Condition?

A pre-existing condition is a physical or mental condition that existed prior to being covered on your health benefit plan. Some insurance policies and health plans exclude coverage for pre-existing conditions. For example, your health plan may not pay for treatment related to a pre-existing condition for one year. Check with your insurance carrier to learn how your organization’s health plan treats specific pre-existing conditions.  

Please Note: Insurance plans vary widely and it is always best to contact your insurance provider with you specific questions. 

 

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