What You May Not KNOW or UNDERSTAND About Your Insurance

health insurance

Co-Payment: is a FIXED amount (for example, $25) you pay for a covered health care service, usually paid when you receive the service. This amount can vary by the type of covered health care service. THIS AMOUNT YOU KNOW UP FRONT (it is usually printed on your insurance card).


Deductible: is the amount you owe for health care services your health insurance or “plan” covers BEFORE your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan will not pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services (read your plan).


Co-insurance: is YOUR share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.



Allowed Amount: is the MAXIMUM amount on which payment is based for covered health care services. This may be called “eligible expense”, “payment allowance” or “negotiated rate”. If your provider charges more than the allowed amount, you may have to pay the difference (otherwise known as “balance billing”).



Balance Billing: is when a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may NOT balance bill you for covered services.



Preferred Provider: is a provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.


Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide health services.


QUESTIONS?: read your policy or call your Customer Service Representative so that you can make an informed decision.