Health insurance and health insurance terminology can be tricky and sometimes confusing. That’s why we’ve broken down the most common insurance terms in easy-to-understand language. For more information on the rest of the most common insurance terms, please visit the Health Insurance Glossary.
The Affordable Care Act (ACA), also referred to as “Obamacare” is care that aims to expand access to coverage, control health care costs and improve health care delivery for U.S. citizens and legal residents. Most U.S. citizens and legal residents are now required to have health insurance coverage or pay a penalty to the government. ACA legislation includes the expansion of Medicaid eligibility, the establishment of health insurance exchanges and protects health insurance members from denied coverage due to pre-existing conditions.
A claim is a request for payment that lists the treatment performed. It’s sent to your insurance company after you receive get covered services.
Coinsurance is the percentage you owe for certain some covered services after reaching your deductible. For example, when you pay 20%, your plan pays 80%.
A copay is a fixed dollar amount that you pay upfront each time you pay for covered services. Copays can vary based on the service, such as when: seeing your primary care provider, visiting a specialist, or filling a prescription might all have different copays.
A deductible is the set amount you pay for covered services or drug costs before your plan starts paying.
A drug formulary is a list of drugs your insurance plan covers. A drug’s formulary may also impact how much you pay for each drug.
The Explanation of Benefits (EOB) is a document that explains the costs for services you received. This includes what the provider billed for, what Highmark paid, and what you will need to pay. The EOB is not a bill, it’s a summary of the charges and payments related to your medical care. It’s designed meant to help you understand how your plan covers the services you received. Members get an EOB after we process certain types of claims. The EOB might include:
Member ID number
Information about your coinsurance, copay and your deductible
Member ID number
What you owe the provider
The out-of-pocket is costs are not covered by your plan. These include co-payments, coinsurance, deductibles and fees paid for treatment or prescriptions.
The total maximum out-of-pocket is the most you’d you pay for any covered services within a plan year. Your deductible, coinsurance, and copays all go toward meeting it. If you hit this amount, your plan pays 100% of covered services.
All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies. This website is operated by Highmark, Inc. and is not the Health Insurance Marketplace website. It also does not display all Qualified Health Plans available through the Health Insurance Marketplace website. To see all available Qualified Health Plan options, go to the Health Insurance Marketplace website at HealthCare.gov.
Highmark Blue Cross Blue Shield or Highmark Blue Shield are Medicare Advantage HMO, PPO, and/or Part D plans with a Medicare contract. Enrollment in these plans depends on contract renewal. ®Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Benefits and/or benefit administration may be provided by or through the following entities, which are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. PA: Your plan may not cover all your health care expenses. Read your plan materials carefully to determine which health care services are covered. For more information, call the number on the back of your member ID card or, if not a member, call 866-459-4418. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Visit our website to view the Access Plan required by the Health Benefit Plan Network Access and Adequacy Act. You may also request a copy by contacting us at the number on the back of your ID card. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.
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