Get to know a bit about health insurance
- There are many types of health insurance plans ranging in price, provider choice and coverage.
- When you receive care from a provider, you may have to pay a copayment (a flat dollar amount) and/or a coinsurance (a percentage of the amount) for health care services (such as an office visit, lab work or an X-ray).
- You may have to meet a deductible each year before your health plan begins paying benefits.
- In-network providers have an agreement with the health plan to participate as a health care provider for a given plan. Plan benefits are better when services are rendered by an in-network provider.
- Plans typically have a calendar or plan year out-of-pocket maximum, which is the most you'll pay for covered health services during the plan year.
- After you receive care, the provider will submit a claim for services. Your health plan or plan sponsor will send payment to the provider. You’ll receive an Explanation of Benefits, which shows how the claim was paid.
- Your provider sends you a bill that shows what was paid and what you still owe for the care received. It’s your responsibility to pay the provider the remaining balance.
Health insurance words and phrases
Like any industry, health insurance has its own terminology. Before you receive care, get to know what an insurance word or phrase means. The more you know, the more you can make the most of your benefits and your health. Here are a few terms you may hear:
Benefit summary is a description of your benefits and copayments. If you are a commercial Providence Health Plan member, you can view your benefit summary online once you have registered for a myProvidence account.
Calendar year is January 1 through December 31.
Coinsurance is the percentage of cost that you may need to pay for a covered service. The plan pays the rest of the cost of the service. Coinsurance amounts are listed on your benefit summary.
Copayment, or copay, is the fixed dollar amount you pay for a covered service at the time the care is provided. Copay amounts are listed on your benefit summary.
Deductible is the amount of money that an individual must pay out-of-pocket for medical services before the health plan pays its portion. Deductibles are usually per person, or per family, per calendar year. For example, you may need to meet a $1,000 per person (or $3,000 per family) calendar year deductible before your health plan benefits begin to pay for your care.
Durable medical equipment (DME) is equipment that is primarily and customarily used to serve a medical purpose and generally is not useful to a person in the absence of illness or injury. It can withstand repeated use and is generally considered to be safe and effective for the purpose intended. DME may include items such as oxygen, wheelchairs and other medically necessary equipment required for the treatment of an illness or injury.
An emergency medical condition is a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate attention would place the health of a person (or a fetus, in the case of a pregnant woman) in serious jeopardy.
A family practice physician is a licensed personal physician/provider trained to diagnose and provide health care to patients of all ages. These providers are trained to provide routine gynecological care (including the annual gynecological exam) and some also provide obstetric care.
A general practice physician is a licensed personal physician/provider trained to diagnose and provide health care services, including routine gynecological care and the annual gynecological exam, to patients of all ages.
A gynecologist is a licensed physician specializing in the diagnosis and treatment of the diseases of women's reproductive systems. You may choose to have a plan gynecologist provide your annual gynecological examination. Some gynecologists have been approved to act as personal physician/providers and will be listed as such in the provider directory.
Member identification cards are issued to each member enrolled in Providence Health Plan. The card identifies you as a plan member and includes important information about your coverage. Always present your card when you seek medical care.
Out-of-pocket maximum is the limitation on the amount of money you will have to spend for specified covered health services in a calendar year. This maximum amount is shown on your benefit summary.
Preventive care is routine services, such as screenings and immunizations, for the purpose of health maintenance and/or the early detection of health care conditions. Providence Health Plan covers certain preventive care services in full when received from an in-network provider. For more information, read Coverage of Preventive Care Services or refer to your benefit summary and/or member handbook for details.
Prior authorized services are medical services or prescription medications that require you and/or your provider to seek plan approval before receiving care. Final determination of plan coverage will be based on your plan's covered benefits and eligibility on the date of service.
A specialist is a nurse, physician or other health care professional who has advanced education and training in one clinical area of practice.
A subscriber is the employee of the group whose employment or membership in the group establishes eligibility for his or her dependents under the Providence Health Plan policy.
Usual, customary, and reasonable charges (UCR) are charges that the plan determines fall within a range of those most frequently charged for services and supplies. The amount determined is based on charges in the community where the services and supplies were furnished, by those who provide them.
See your Providence Choice or PEBB Statewide member material for additional health insurance terms and definitions.