A little knowledge goes a long way when it comes to understanding your benefits! At J.P. Farley, we’re dedicated to member service.
To help you navigate and better understand your healthcare plan, we’ve put together a list of terms to know and answered a few common questions.
What is a Provider Network?
A provider network is a group of healthcare professionals who have joined together to offer services at a contracted rate. If your plan works with a specific network, those providers are designated ‘in-network’.
What is a Deductible?
A deductible is the out of pocket amount that a plan member is responsible for paying per year before the health plan will cover the cost of medical treatment. Check your plan document to see what your set deductible cost is, and how much you pay for covered services after you meet the deductible.
What is a Copay?
A copay is the payment you make for medical visits and/or prescriptions in addition to what your health plan will pay.
What is Coinsurance?
Coinsurance is a form of cost sharing between the plan participant and the health plan. The participant pays a share of the payment made against the claim, usually represented in a percentage. For example, if the plan is 80/20, your health plan would cover 80% of the claim, and you would pay 20%.
What is an Out of Pocket Max or Limit?
An out of pocket maximum is the most the participant will pay for covered services within a plan year. After you meet your out of pocket maximum meeting copayments, coinsurance and deductibles, your plan pays 100% of the cost of covered benefits. Check your plan document to see what medical payments are including in your out-of-pocket limit.
What is a Dependent?
A dependent is a spouse or child that is covered by the primary participant’s health plan.
What is an Effective Date?
The effective date is the date that the plan participant’s coverage begins.
What is an In-Network Provider?
A healthcare professional, hospital or pharmacy is considered in-network if that provider is a part of the health plan’s preferred providers. These providers generally offer a discounted rate to the plan participant as negotiated by the insurance company. Be aware, your in-network doctor or hospital may be out-of-network for some services. Plans use the term in-network, preferred, or participating for providers in their network. See your plan to review how different providers are covered.
Understanding an EOB
What is an EOB?
An explanation of benefits (EOB) is a statement that is sent by a health insurance company to the plan participant. This form explains the medical treatment and services that were paid for by the health insurance company on their behalf. The EOB describes the service performed, fee from the medical provider, and amount the patient is responsible for.
Is an EOB a bill?
An EOB is not a bill, but will show if the plan participant is responsible for any remaining payment to the medical service provider. The provider will bill the participant for any remaining payment.
Balance Billing refers to any amount left after the amount your health plan has covered.
When you visit a provider who is a part of your PPO network, you receive a network discount and are not responsible for any balance bills received.
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 amount left unpaid is then the responsibility of the member.