Guide to Healthcare Coverage Terms
Learn the definitions of some common insurance terms to better understand your insurance plan. Click on the “+” symbol to learn more about each term.
When you have co-insurance, you are required to pay a certain percentage of the total cost of medical services. Some plans have different co-insurance percentages before or after you have met your deductible, or different co-insurance percentages for different procedures or services.
A co-pay is the amount you pay for doctor’s visits, emergency room visits and often for prescriptions. Some plans require you to pay co-pays instead of meeting a deductible. Other plans may require you to do both. Your co-pays do not count toward the deductible amount, but do count toward your out-of-pocket limit.
The deductible is the amount you pay during a coverage period (usually one year) for covered healthcare services before your plan begins to pay. The deductible may not apply to all services and not all plans have a deductible. For some plans, the deductible may only apply to out-of-network services.
In-Network vs Out-Of-Network
In-network services are services that your health plan covers that you can get at lower or no co-pay/co-insurance. Out-of-network services are those that are still covered by your plan, but may have a higher co-pay or co-insurance than in-network services.
Your member ID is a unique number connected to you that allows healthcare providers and their staff to verify your coverage and arrange payment for services. It’s also the number health insurance companies use to look up specific members and answer questions you may have about your claims and benefits. Your member ID number can be found on your member ID card.
Your health plan network is made up of the facilities, providers (doctors, nurses) and suppliers your health plan has contracts with to provide health care services.
The out-of-pocket limit is the total you must pay for before your plan begins paying 100% of covered health costs for the rest of the year. Generally, co-pays, your deductible, co-insurance and covered in-network payments count toward this limit.
Primary Care Provider or Provider (Doctor)
A primary care provider is a doctor or other healthcare provider that you can see for continued care. You can choose your primary care provider through your health plan’s website. Some plans may automatically assign one to you, but you can change it at any time.
A premium (or co-premium) is the amount you pay for health insurance coverage every month, whether or not you go to the doctor. For caregivers covered through SEIU 775 Benefits Group, their co-premium is just $25 a month.
Outpatient Services vs Inpatient Services
An inpatient service is one that requires you to stay at a hospital overnight. Some examples may be delivering a baby or some surgeries. An outpatient service is any service that does not require you to stay at a hospital.