Deductible

A specific dollar amount that your health insurance company requires you to pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible.

Out-of-Pocket Maximum

Out-of-pocket maximums apply to all medical plans. This is the maximum amount you will pay for health care costs in a

calendar year. Once you have reached the out-of-pocket maximum, the plan will fully cover eligible medical expenses for the rest of the plan year. If you see an out-of-network provider, you will still be responsible for out-of-pocket costs that are above the “reasonable and customary” fees.

Copayment

A specific charge that you pay for a specific medical service or supply, also referred to as a "copay." For example, your health insurance plan may require a $20 copayment for an office visit or brand-name prescription drug, after which the insurance

company pays the rest.

Coinsurance

The amount that you are required to pay for covered medical services after you've satisfied any co-payment or deductible

required by your health insurance plan. Coinsurance is typically a percentage of the charge for a service. For example, if your insurance company covers 80% of the allowable charge for a specific service, you are responsible for the remaining 20% as

coinsurance

In-Network Provider

A healthcare professional, hospital, or pharmacy that has a contractual relationship with your health insurance company. This contract establishes allowable charges for specific services. In return, healthcare providers gain patients; primary care physicians may receive a capitation fee for each patient assigned to their care. An out-of-network provider is a healthcare professional, hospital, or pharmacy that is not part of your health plan's network of preferred (in-network) providers. You will pay more for services received from out-of-network providers because you will be responsible for costs considered above the “reasonable and customary” fees.

Out-of-Pocket Maximum

Out-of-pocket maximums apply to all medical plans. This is the maximum amount you will pay for health care costs in a

calendar year. Once you have reached the out-of-pocket maximum, the plan will cover most eligible medical expenses for the rest of the year.

Claim

A request by a plan member, or a plan member's health care provider, for the insurance company to pay for medical services.

Qualifying Life Event

A life event that allows you to make changes to your insurance coverage that otherwise are only allowed during the annual Open Enrollment period.

Examples of a qualifying life event include, but are not limited to, marriage, divorce, birth or adoption of a child, loss of prior coverage, relocation, and the arrival of a dependent from another country.