Health plan basics

​Health care can be complex – but we can help. Here are basic definitions and explanations so you can get the most from your coverage and your care.

Provider networks

You receive the highest level of benefits (called in-network) when you use participating providers for covered health care services. We have three provider networks: Providence EPO Network, Providence Choice Network and Providence Neighborhood Network. See maps and network descriptions.

Is your doctor an individual and family plan participating provider? Search our provider directory.

Non-participating providers

All of our individual and family plans provide benefits for covered services when you see a non-participating provider. When you see a non-participating provider (called out-of-network), you will pay a higher coinsurance on most services and may have a separate deductible. Plus, you will pay any amounts over usual, customary and reasonable Rates (UCR). These rates are based on the service provided and the geographic location of the provider.

Preventive care coverage

We believe that getting the right preventive care is essential for maintaining good health. All our plans cover certain preventive care in full* prior to meeting your deductible, including:
  • Well baby care (from a personal physician/provider only)
  • Periodic health examinations (from a personal physician/provider only)
  • Routine immunizations and shots
  • Annual women's gynecological exams
  • Mammograms
  • Colorectal cancer screening exams (age 50 and over)
  • Pediatric routine eye exams (one per calendar year)
*Based on Affordable Care Act regulations

Deductibles

An annual deductible is the amount you pay for covered services before the plan will begin to pay for these services. A new deductible must be met each calendar year.

Choosing a plan that works best for you – one with a higher or lower deductible – is a decision that is unique to your own coverage needs:
  • A higher deductible plan means a lower monthly premium. In exchange for a lower premium, you pay a larger amount for certain covered services before the plan will begin to pay for those services.
  • A lower deductible plan means a higher monthly premium. However, the plan will begin to pay sooner for certain covered services.
  • Deductible carryover: For Balance, Value, Choice and Connect plans, deductible amounts paid for services received in the last three months of a calendar year will carry forward and apply toward the deductible for the following year.

Copayment and coinsurance

After meeting your annual deductible, you and the health plan will begin to share the costs of covered health services through copayments and coinsurance.
  • Copayment : A fixed dollar amount you pay for a covered service at the time care is provided. If a copay is listed as $20 for an office visit, you pay $20 at the time of service.
  • Coinsurance: A percentage of cost you pay for a covered service. If a plan lists 20 percent for a health care service that costs $125, you would pay $25 (20 percent of $125).

Out-of-pocket maximum

To protect you from catastrophic costs, our plans include an annual out-of-pocket maximum. An out-of-pocket maximum is the total amount you pay for covered services, including the deductible, in a calendar year. After you meet your out-of-pocket maximum, the plan will pay 100 percent of covered services for the remainder of the calendar year. (Certain services do not apply to the out-of-pocket maximum.) The out-of-pocket maximums vary by plan.