Primer on Health Insurance Concepts and Terminology Dependent: One who relies on another for finan- cial support like a spouse or child. Clinical Fee: Full-time students are automatically charged this fee. Fee makes students eligable for provider visits at SHS for no additional charge! Referral: The recommendation by a medical professional to see a specialist. Preferred (in-network) Provider Deductible Co-Insurance Maximum Benefits Co-pay Out-of-Pocket Maximum Non-Preferred (out-of-network) Provider Some Basic Vocab The percentage of covered medical expenses paid by the insurance carrier. Co-Insurance is calculated based on allowable and reasonable charges. Your share of the costs of a covered service will vary depending on if the care is in-network or out-of-network. Maximum amount insured individual (you) would be expected to pay during policy year Includes deductible. Does not include co-pay. After you have reached your out-of-pocket maximum, your medical bills will be covered by your health insurance company for the rest of the year with some exceptions. Maximum amount that insurance will pay for medical expenses. After reaching the maximum benefit the insured individual is responsible for paying the negotiated charges. Provider that has contracted to provide services for a negotiated charge. An insured individual who receives care from a preferred provider can be charged only the negotiated rate (co-pay). Provider that has not contracted to provide services for a negotiated charge. An insured individual who receives care from a non-preferred provider can be charged the difference between the actual charge and the part paid by the insurance carrier. Amount of care expenses that must be paid by YOU before an insurer will pay any expenses. Different deductibles apply for in-network and out-of-network care. Deductible is typically annual (must be paid each year) Fixed dollar amounts (for example, $15) you pay for covered health care by an in-network (preferred) provider, usually when you receive the service.

Primer on Health Insurance Concepts and Terminology

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Primer on Health Insurance Concepts and Terminology

Dependent: One who relies on another for finan-cial support like a spouse or child.

Clinical Fee: Full-time students are automatically charged this fee. Fee makes students eligable for provider visits at SHS for no additional charge!

Referral: The recommendation by a medical professional to see a specialist.

Preferred (in-network) Provider

Deductible

Co-Insurance

Maximum Benefits

Co-pay

Out-of-Pocket Maximum

Non-Preferred (out-of-network) Provider

Some Basic Vocab

The percentage of covered medical expenses paid by the insurance carrier. Co-Insurance is calculated based on allowable and reasonable charges. Your share of the costs of a covered service will vary depending on if the care is in-network or out-of-network.

Maximum amount insured individual (you) would be expected to pay during policy year

Includes deductible. Does not include co-pay.

After you have reached your out-of-pocket maximum, your medical bills will be covered by your health insurance company for the rest of the year with some exceptions.

Maximum amount that insurance will pay for medical expenses.

After reaching the maximum benefit the insured individual is responsible for paying the negotiated charges.

Billed Services

Medical services and procedures for which the provider bills either the insurance company and/or the patient

May or may not be a benefit under the terms of the insurance policy

Benefits (a.k.a. Covered Medical Expenses):

Those services actually covered by the insur-ance policy

The amounts actually paid by the carrier

Billable services that are not covered by the insurance policy are “exclusions”

Provider that has contracted to provide services for a negotiated charge.

An insured individual who receives care from a preferred provider can be charged only the negotiated rate (co-pay).

Provider that has not contracted to provide services for a negotiated charge.

An insured individual who receives care from a non-preferred provider can be charged the difference between the actual charge and the part paid by the insurance carrier.

Amount of care expenses that must be paid by YOU before an insurer will pay any expenses. Different deductibles apply for in-network and out-of-network care.

Deductible is typically annual (must be paid each year)

Fixed dollar amounts (for example, $15) you pay for covered health care by an in-network (preferred) provider, usually when you receive the service.