Insurance can be daunting to navigate alone. This form outlines the common terms associated with insurance operations. As you or your loved one is exploring treatment options it can be very helpful to connect with the member services line on the back of your card. This line can connect you with a care advocate to help you understand the parameters of your plan’s coverage, benefits and costs. This step can be time consuming but is often a valuable opportunity to get a grasp on how your benefits and reimbursement will work throughout the treatment process.
Basic Terms:
In-Network Benefits
Benefits and coverage associated with the plan and providers that are in network.
Co-pays and Deductibles will apply.
Out-of-Network Benefits
Benefits and coverage associated with the plan and providers that are out-of-network.
Co-insurance and Deductibles will apply.
Co-Pay
Flat fee you are responsible for at the time of services rendered (ONLY applies to IN NETWORK).
Co-Insurance
The percentage the individual is responsible for per service, paid by the member, after the deductible is met.
Can be applicable for In or Out-of-Network benefits
Deductibles
The amount an individual must pay before insurance coverage kicks in. There are typically two deductibles with any plan (In and Out-of-Network Deductibles). There are some exceptions to this however, for example, HMOs do not have out-of-network benefits. Once the deductible is met, they are only responsible for the co-pay or co-insurance.
Out-of-Pocket Max
The maximum amount that an individual is responsible for in a coverage year (Note- if the insurance is out of network, only the ALLOWABLE charge contributes towards the Out of Pocket. Even if the client has met their out of pocket, they will still be responsible for any balance after the allowable when the insurance is out of network.)
Coverage year
Insurance policies may start on the fiscal or calendar year. It is important to know when your policy year starts and ends so you are prepared for deductibles, etc. to start over.
Verification of Benefits (VOB)
Call to verify benefits and plan information.
Explanation of Benefits (EOB)
The forms you receive from your insurance company outlining plan coverage and patient responsibility.
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