Common Health Care Terms

The technical terms associated with modern medical plans can be difficult to understand sometimes. The following are some key concepts that may help you decipher your plan:

Annual Deductible

The amount you or a covered family member pays for covered care each year before the plan pays benefits. The deductible does not apply to certain types of medical care, such as preventive care.

Coinsurance

A percentage you or a covered family member pays for covered services after any annual deductible has been satisfied. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Copayment

A fixed dollar amount you or a covered family member pays for covered services at the time of service.

In-Network vs. Out-of-Network Provider

In-network providers (including facilities and suppliers) are those that have specifically contracted with your health insurance company to charge an agreed upon rate. It will generally be less expensive to utilize these “participating” providers, versus out-of-network providers who are not contractually obligated to charge an agreed upon fee. Copayments, deductibles and coinsurance also cost more for out-of-network providers.

Out-of-Pocket Maximum

The accumulated amount you or a covered family member pays toward deductibles and coinsurance, and certain copayments in a benefit year. Under our medical plans, this maximum includes deductible amounts, in-network office, hospital, and emergency room copayments and coinsurance.

Preventive Care Benefits and Prescription Drugs

Coverage for certain health screenings such as routine physicals, well-baby care, mammograms and other early-detection testing, are covered at 100 percent without the deductible requirement when you use network providers (subject to certain age-appropriate and frequency guidelines). Certain prescription drugs classified as preventive (e.g., certain contraceptives) are covered at 100 percent in all plans.

Summary of Benefits and Coverage (SBC) Available

Under Health Care Reform, health insurers are required to provide members with a Summary of Benefits and Coverage (SBC), a standardized “consumer friendly” document designed to help you understand and evaluate your health insurance choices.

SBCs for each medical plan will be available online in the Document Library. Hard copies will be available upon request from benefits@applebank.com.