Sage
The words on your plan, explained the way a person would explain them. No account, no jargon inside the definitions.
Back to SageThe amount you pay for covered care out of pocket before your plan starts paying its share. Ask your provider for an in-network cost estimate, and you can expect that cost to be the amount you pay towards your deductible. Some services, like preventive care, are covered before you meet it. HSA and FSA funds can pay for the bills that go towards your deductible.
With a $1,500 deductible, you pay the first $1,500 of covered care. In-network and out-of-network care usually have separate, different deductibles.
A fixed dollar amount you pay for a covered service, known up front. On many plans it does not depend on your deductible.
A $30 copay to see your doctor means you pay $30 at the visit, no matter what the full bill is.
Your share of a covered service written as a percentage, usually after you have met your deductible. Because it is a percentage of the plan's negotiated price, the exact dollar amount is not known until the care is billed.
20% coinsurance means if the plan's allowed amount for a service is $200, you pay $40 and the plan pays the rest.
The most you have to pay for covered care in a plan year. Once you hit it, the plan pays 100% of covered services for the rest of the year. Premiums and non-covered care do not count toward it.
After your deductibles, copays, and coinsurance add up to your out-of-pocket maximum, you pay nothing more for covered in-network care that year.
The price your plan has agreed to pay an in-network provider for a service. Your coinsurance is calculated from this number, not the provider's sticker price.
A provider may bill $300, but if the plan's allowed amount is $200, your 20% coinsurance would be $40, based on the $200. The 20% coinsurance applies after the deductible has been met.
The doctors, hospitals, and pharmacies that have agreed to your plan's negotiated prices. Staying in the network is how you keep your costs predictable.
Your plan's network is tied to your plan prefix. You can look up who is in it in the provider directory.
A provider that is part of your plan's network and bills at the plan's negotiated rate. Your cost-sharing is lower, and you are protected from balance billing.
An in-network specialist might be a $60 copay. The same visit out-of-network could be 40% coinsurance after a much higher deductible.
A provider that has not agreed to your plan's rates. You usually pay more, often a higher deductible and higher coinsurance, and you can be balance billed for the rest.
Out-of-network care often runs against a separate, higher deductible. Confirm a provider is in-network before you book to avoid a surprise bill.
When an out-of-network provider bills you for the difference between their full charge and what your plan paid. In-network providers cannot do this.
If an out-of-network provider charges $300 and your plan's allowed amount is $200, they may bill you the extra $100 on top of your coinsurance.
The first three letters of your member ID. It identifies your specific plan and network, and it is what a provider directory uses to show who is in-network for you.
Enter your plan prefix and ZIP code in the provider directory to see only the providers in your network.
An okay from your primary care doctor to see a specialist. Some plans require one before they will cover the specialist visit; many PPO plans do not.
If your plan does not require referrals, you can book a specialist directly. If it does, the specialist visit may not be covered without one.
The bill your provider sends your plan for a service. The plan processes it, pays its share, and tells you what you owe.
One visit can create several claims, for example the doctor and the lab bill separately, which is why you might see more than one charge.
A summary your plan sends after a claim. It is not a bill. It shows what the provider charged, what the plan paid, and what you owe.
If your EOB and your provider's bill do not match, that is worth checking before you pay, sometimes the EOB is still processing.
The rules that decide which plan pays first when you are covered by more than one, so the plans do not both pay for the same thing.
If you have your own plan and are also on a spouse's plan, coordination of benefits sets which one is primary.
Care your plan considers appropriate and needed to diagnose or treat a condition. Coverage of some services depends on the plan agreeing it was medically necessary.
A service can be covered in general but still be denied for a specific claim if the plan does not consider it medically necessary, which a Health Navigator can help appeal.
Approval your plan requires before it will cover certain services or drugs. Getting it does not guarantee the claim is paid, but skipping it when it is required usually means you pay in full, plus a 50% pre-cert penalty.
Some imaging, surgeries, and medications need preauthorization. Your provider's office usually requests it before the service.
The list of prescription drugs your plan covers, sorted into tiers that set what you pay. A drug not on the formulary may not be covered.
Checking the formulary tells you a drug's tier, and therefore its cost, before you fill it.
The cost level a drug sits in on the formulary. Lower tiers (usually generics) cost less; higher tiers (brand and specialty drugs) cost more.
A Tier 1 generic might be a $10 copay while the Tier 3 brand version of the same drug is $70. Same medicine, very different cost.
A generic has the same active ingredient as the brand-name drug and works the same way, but sits in a lower tier and costs much less.
Asking your doctor or pharmacist whether a generic exists is one of the easiest ways to lower a prescription cost.
A pharmacy that handles complex, high-cost drugs (often injectables or biologics). Plans usually require these drugs to be filled there, or they are not covered.
A biologic for an autoimmune condition typically must go through the specialty pharmacy and often needs preauthorization.
A rule that you try a preferred, usually lower-cost drug first, and only move to the more expensive one if the first does not work for you.
Your plan may cover the brand drug only after you have tried the generic, unless your doctor documents a reason you need the brand.
Getting a longer supply (often 90 days) of a regular medication delivered by mail, usually at a lower cost per month than picking it up monthly.
For a maintenance drug you take every day, a 90-day mail-order fill often costs less than three monthly retail fills.
A plan type that lets you see specialists without a referral and use out-of-network providers at a higher cost. You save the most by staying in-network.
On a PPO you can book a specialist directly, but going out-of-network still means higher cost-sharing.
A plan with a higher deductible and lower premium. Most care is coinsurance after you meet the deductible rather than a flat copay, and it can be paired with an HSA.
On an HDHP, a doctor visit is usually a percentage after your deductible, not a fixed copay, so the cost depends on the visit.
A tax-advantaged account you can pair with a high-deductible plan to pay for care. The money is yours, rolls over each year, and is not taxed when used for eligible care.
You can use HSA dollars to pay toward your deductible or coinsurance, which softens the higher deductible of an HDHP.
Routine care meant to keep you healthy or catch problems early, like annual checkups, screenings, and vaccines. In-network preventive care is usually covered at no cost to you, even before your deductible.
Your annual physical is typically $0 in-network. If the doctor also treats a specific complaint during it, that part may be billed separately.
Care done to find out what is wrong, or to follow something that has already been found. It is the same test as a screening in many cases, ordered for a different reason, and it is billed at your normal copay, coinsurance, or deductible rather than being free.
A routine mammogram with no symptoms is preventive and free in network. The same mammogram to look at a lump is diagnostic, so your plan's normal share applies.
Urgent care handles non-life-threatening problems that still need attention today, usually at a much lower cost than the emergency room. The ER is for true emergencies and carries a far higher copay.
For a sprain or a fever, urgent care may be a $60 copay while the ER is a $350 copay. For chest pain or trouble breathing, the ER is the right call regardless of cost.
The doctor or clinician you see first for checkups, everyday illnesses and questions about your health. Family doctors, internists and pediatricians are primary care, and many plans also count OB-GYNs, nurse practitioners and physician assistants.
A primary care visit usually costs less than a specialist visit. Your plan document lists which kinds of providers count as primary care.
Care you get by video or phone instead of in person, from a doctor, nurse practitioner or therapist. It works for many everyday problems, prescription refills and therapy sessions.
On some plans a virtual visit costs less than an urgent care visit. Anything that needs a hands-on exam still means going in.
Outpatient care is care where you go home the same day, even if it happens at a hospital. Inpatient care means you are formally admitted to a hospital, usually overnight or longer.
An overnight stay for observation can still count as outpatient if you were never admitted. Inpatient stays often need approval ahead of time and are priced differently, so it is worth asking which one you are.
A facility, separate from a hospital, that does surgeries and procedures where you go home the same day.
The same procedure can cost less at a surgery center than at a hospital outpatient department. You may get separate bills from the center, the surgeon and the anesthesia provider.
Services that support your main care, like lab tests, imaging, anesthesia, supplies or therapy. They are often billed separately from the visit or procedure itself.
One outpatient surgery can produce a facility bill, a surgeon bill and a separate bill for anesthesia or lab work. Each one follows your plan's rules for that kind of service.
A cap on how much a plan will pay, or how many visits it covers, for a certain benefit. The cap can reset every year or apply over your whole lifetime. Once you reach it, you pay for that benefit yourself.
A plan might cover 60 therapy visits a year, or pay up to a set dollar amount for fertility treatment over your lifetime. Your plan document lists each limit.
Care for mental health and for Substance Use Disorder, including alcohol and drug use, from therapy and counseling to psychiatry and treatment programs.
A therapy visit is behavioral health care. Many plans price it like a doctor visit, while testing and intensive programs are often priced differently.
Comfort-focused care for someone with a terminal illness, plus support for their family. The goal is relief from pain and symptoms rather than a cure, and it often happens at home.
Hospice can include nursing visits, medical equipment and counseling for the family. Many plans require approval before it starts.
A mistake in the codes a provider uses to tell the plan what was done and why. A wrong code can make a covered service look uncovered, or bill a routine visit as something more expensive.
A screening billed with a diagnostic code can lose its no-cost preventive coverage. If a charge looks wrong, ask the provider's billing office for an itemized bill and a code review.
When a provider bills the separate pieces of one procedure as individual charges instead of using the single code that covers the whole thing. It usually makes the total higher and is a common billing error.
If your bill lists many small line items for one procedure, you can ask the billing office whether it should have been billed as one.
The plan's check of whether a treatment is medically necessary and the right fit before it pays. It can happen before care (as preauthorization), during a hospital stay, or after a claim comes in.
A letter saying a service is “under review” usually means the plan is checking medical necessity. Your doctor can send records to support the request, and you can appeal a denial.
An account set up through your employer where you set aside money from your paycheck, before taxes, to pay for health costs like copays, deductibles and prescriptions.
FSA money usually has to be spent within the plan year, though some employers allow a short grace period or a small rollover. Unlike an HSA, the account stays with your employer.
An account your employer funds to pay you back for some of your out-of-pocket health costs, like deductibles and coinsurance. You don't put your own money in.
If your employer puts $500 in an HRA, that money can cover part of a bill that went toward your deductible. What it covers and whether it rolls over are set by your employer.
A type of plan that only covers care from its own network, except in emergencies. You usually pick a primary care provider and need a referral to see a specialist.
HMOs often cost less in exchange for less choice. Seeing a doctor outside the network without approval usually means paying the full cost yourself.
A mix of an HMO and a PPO. You usually pick a primary care provider and need referrals, but you can see out-of-network providers if you're willing to pay more.
On a POS plan, seeing an in-network specialist with a referral costs less than going out of network on your own.
The card, or the part of your ID card, that a pharmacy uses to bill your prescription coverage. Some plans use a separate company for prescriptions, so this card can carry different numbers than your medical card.
If the pharmacy can't find your coverage, show them your pharmacy card. You can usually pull up a digital copy in your plan's app.
A health problem you had before your coverage started, like asthma, diabetes, or a past cancer. Under the Affordable Care Act, job-based and marketplace plans can't refuse to cover it or charge you more because of it.
If you were treated for a condition before joining your plan, that care is covered the same way as anyone else's.
The 2010 federal law that sets basic rules for most health plans. It requires many preventive services at no cost, bans turning people away for pre-existing conditions, and lets children stay on a parent's plan until 26.
The no-cost checkups and screenings on your plan come from this law, as long as you see an in-network provider.
A federal law that protects your health information. Your plan, doctors and pharmacies can only share details about your health and care with your permission, or for reasons the law allows, like treatment and payment.
Your employer can't use your health information to make job decisions, and you have the right to a copy of your own medical records.
The federal health program for people 65 and older and for some younger people with disabilities. Part A covers hospital care and Part B covers doctor visits and outpatient care. Medicare Advantage plans offer that coverage through private insurers.
If you have Medicare and job-based coverage at the same time, one pays first and the other pays second. Your plan can tell you which one goes first.
A health program run by each state with federal funding, for people with lower incomes and some people with disabilities. A related program, CHIP, covers children in families that earn too much for Medicaid.
Rules and program names differ by state. If your income changes, you may qualify even if you didn't before.
Prototype. General definitions, not advice about your specific plan. Not affiliated with any insurer.