Terms to Know
A: A provider network is a group of healthcare professionals who have come together to offer bundled services at a contracted rate. If your plan works with a specific network, those providers are designated as ‘in-network’.
A: A deductible is the annual out-of-pocket limit that you are responsible for paying before the health plan will cover the full cost of medical treatment. Check your plan documents to see what your deductible is and whether you are required to pay for covered services after you meet that deductible.
A: A copay is the amount you are required to pay out of pocket for medical visits and/or prescriptions in addition to what your health plan will pay.
A: Coinsurance is a form of cost sharing between plan members and the health plan. You will be required to pay a share of the payment made against your claim, usually represented as a percentage. For example, if you have an 80/20 plan, your health plan would cover 80% of the claim cost, and you would pay the remaining 20%.
A: An out-of-pocket maximum is the threshold of what you will be required to pay for covered services within a plan year. After you meet your out-of-pocket maximum through copayments, coinsurance and deductibles, your plan pays 100% of the cost of covered benefits for the rest of the plan year. Check your plan document to see what medical payments are included in your out-of-pocket maximum.
A: A dependent is a spouse or child that is covered under your health plan.
A: The effective date is the date that your coverage begins.
A: Plans use the term in-network, preferred, or participating for providers in their network. A healthcare professional, hospital or pharmacy is in-network if that provider is a part of your health plan’s preferred providers. These providers generally offer a discounted rate as negotiated by the insurance company. Be aware that your in-network provider or hospital may be out-of-network for some services. See your plan documents to review how different providers are covered.
EOBs
A: An explanation of benefits (EOB) is a statement that a health insurance company sends to explain the medical treatment and services that the health insurance company paid for on your behalf. The EOB describes the service performed, the fee from the medical provider, and any remaining cost the patient is responsible for.
A: An EOB is not a bill, but will show if you are responsible for any remaining payment to the medical service provider. The provider will bill you directly for any remaining payment.
A: Explanation of Benefits are mailed to members following claim processing. If you do not receive an EOB by mail, J.P. Farley is typically able to process claims within a few days following the receipt of your claim from your provider. Your plan also offers the ability to view EOBs online.
Billing
A: Balance Billing refers to any remaining balance after your health plan has paid out a claim.
A: When you visit a provider who is part of your PPO network, you will receive a network discount and are not responsible for any balance bills received.
A: If you visit a provider who is not a part of your PPO network, your health plan will cover up to a certain dollar amount. Any balance left unpaid is then your responsibility to pay.
If you have additional questions that aren’t answered above, please reach out. We’re always happy to help!
