The discounted amount that in-network medical providers or pharmacies are “allowed” to charge a plan member.
The member’s share of the cost of a covered service. For example, if a plan pays 80%, the member’s co-insurance is 20%.
A fixed amount paid for a covered service. For example $75 for urgent care.
The dollar amount of covered services an individual must pay each plan year before the plan begins reimbursement.
Benefits for covered services rendered by a network of contracted physicians and hospitals. Users of in-network providers receive greater benefits for services.
Any person covered under a plan, including the employee, a spouse or a child. Sometimes also referred to as enrollee or participant.
A group of physicians and hospitals who have contracted to provide medical services at a reduced rate.
Benefits for covered services rendered by non-contracted physicians and hospitals. PPO plans cover services both in- and out-of-network. Exclusive provider network plans (i.e. IU Health HDHP) do not cover out-of-network providers except for emergency care away from home.
The out-of-pocket maximum helps protect you from high medical bills. Once the health plan’s out-of-pocket maximum is reached, the plan pays 100% of covered charges for the remainder of the plan year. Plan deductible and percent co-insurance count toward the out-of-pocket maximum. Fixed dollar co-payments (e.g., urgent care, emergency room) are covered without a deductible; they count only toward the out-of-pocket maximum, not the deductible.
Preferred Provider Organization (PPO)
A Preferred Provider Organization is a medical plan that uses a network of contracted physicians and facilities to provide services at discounted rates. A PPO gives members the option of using providers outside the network; but with a separate deductible, and higher co-insurance and balance billing for charges in excess of the allowed amount.
High cost, scientifically engineered drugs that are usually injected or infused.