Key Insurance Terms

Commonly used health insurance terms

In-network

Health insurers negotiate fees and sign agreements with health care providers and facilities, creating a network of providers. Providers that are part of these agreements are considered in-network for members. Generally speaking, members pay less at these in-network facilities in the form of lower copayments and deductibles.

Out-of-network

Providers and facilities that do not have a contract with a health insurer are considered out-of-network. Providers and facilities may be more expensive and may not be covered through the health plan.

Out-of-pocket-maximum

This is the maximum amount that you will have to pay under your plan. Any care for covered services you get after you meet your out-of-pocket maximum will be covered 100 percent.

Deductible

A deductible is the amount you pay before your health plan starts paying for covered services. For example, if your plan has a $1,000 deductible, you will need to pay the first $1,000 of the costs for the services you receive. Once you have paid this amount, your insurance will begin to pay a portion or all of your health care costs up to the out-of-pocket maximum, depending on the plan. If you use a participating provider, your costs are based on our discounted rate.

Coinsurance

Some plans require you to pay a percentage of your medical costs, or coinsurance (for example, your plan will pay 80 percent of the cost for services, you will pay 20 percent). If you use a participating provider, your costs are based on our discounted rate.

Copayments

Also called a copay, it's a set dollar amount you pay for a covered  health service. For example, if you have a $15 copay for a doctor's visit, you simply pay $15 and your plan covers the rest.