Explanation of Benefits (EOB)- An EOB is a statement from your health insurance plan describing what costs it will cover for medical care or products you've received. The EOB is generated when your provider submits a claim for the services you received.
In-Network- The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
Out of Network- The facilities or providers is not a contracted provider through your health insurance plan.
Employee Assistance Program (EAP)- Voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.
No Surprise Act/Good Faith Estimate- The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers.
HSA - Health Savings Account - A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses. By using untaxed dollars in a Health Savings Account (HSA) to pay for deductibles, copayments, coinsurance, and some other expenses, you may be able to lower your overall health care costs. HSA funds generally may not be used to pay premiums.
FSA -Flexible Spending Account-An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, insulin, and medical devices. You decide how much to put in an FSA, up to a limit set by your employer. You aren't taxed on this money.
Claim- A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
Policy Year- A 12-month period of benefits coverage under an individual health insurance plan. This 12-month period may not be the same as the calendar year. To find out when your policy year begins, you can check your policy documents or contact your insurer.
Premium-The amount you pay for your health insurance every month. In addition to your premium, you usually have to pay other costs for your health care, including a deductible, copayments, and coinsurance.
Benefits- The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents. In Medicaid or CHIP, covered benefits and excluded services are defined in state program rules.
Copay- A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
- Let's say your health insurance plan's allowable cost for a doctor's office visit is $100. Your copayment for a doctor visit is $20.
- If you've paid your deductible: You pay $20, usually at the time of the visit.
- If you haven't met your deductible: You pay $100, the full allowable amount for the visit.
Copayments (sometimes called "copays")- can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
- Generally, plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.
Co-insurance-The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
- Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.
- If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.
- If you haven't met your deductible: You pay the full allowed amount, $100.
Example of coinsurance with high medical costs
- Let's say the following amounts apply to your plan and you need a lot of treatment for a serious condition. Allowable costs are $12,000.
- Deductible: $3,000
- Coinsurance: 20%
- Out-of-pocket maximum: $6,850
You'd pay all of the first $3,000 (your deductible).
You'll pay 20% of the remaining $9,000, or $1,800 (your coinsurance).
So your total out-of-pocket costs would be $4,800 — your $3,000 deductible plus your $1,800 coinsurance.
If your total out-of-pocket costs reach $6,850, you'd pay only that amount, including your deductible and coinsurance. The insurance company would pay for all covered services for the rest of your plan year.
Generally speaking, plans with low monthly premiums have higher coinsurance, and plans with higher monthly premiums have lower coinsurance.
Deductible-The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
- After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
- Many plans pay for certain services, like a checkup or disease management programs, before you've met your deductible. Check your plan details.
- All Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible.
- Some plans have separate deductibles for certain services, like prescription drugs.
- Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members.
Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.
Out of Pocket Max- The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
The out-of-pocket limit doesn't include:
- Your monthly premiums
- Anything you spend for services your plan doesn't cover
- Out-of-network care and services
- Costs above the allowed amount for a service that a provider may charge
The out-of-pocket limit for Marketplace plans varies but can’t go over a set amount each year.
- For the 2022 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,700 for an individual and $17,400 for a family.
- For the 2021 plan year: The out-of-pocket limit for a Marketplace plan can’t be more than $8,550 for an individual and $17,100 for a family.
Definitions from healthcare.gov & CMS.gov