Glossary

Balance Bill—A bill from a provider charging you amounts not eligible to be paid. Note: If received, send to ELAP as soon as possible.

Coinsurance—The percentage of the costs of a covered health care service or prescription drug you pay after you’ve paid your deductible. Remember, you pay 100 percent of the full allowed amount until you meet your deductible.

Copayment (Copay)—The amount you pay to a healthcare provider at the time you receive services. You may have to pay a copay for each covered visit to your doctor, depending on your plan.

Covered Service—A healthcare provider’s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan.

Deductible—The amount you pay for most covered services before your health plan starts to pay. The deductible resets at the beginning of the calendar year or when you enroll in a new plan.

Dependent—An eligible person, other than the member (generally a spouse or child), who has health care benefits under the member’s policy.

Exclusions—Specific medical conditions or circumstances that are not covered under a health care plan.

Explanation Of Benefits (EOB)—An EOB is created after a claim payment has been processed by your health care plan. It explains the actions taken on a claim such as the amount that will be paid, the benefit available, discounts, reasons for denying payment and the claims appeal process. EOBs are available both as a paper copy and online.

Generic Drug—A prescription drug that is the generic equivalent of a brand name drug listed on your health plan’s formulary and costs less than the brand name drug.

Inpatient Services—Services received when admitted to a hospital and a room and board charge is made.

Non-covered Charges—Charges for services and supplies that are not covered under the health plan.

Outpatient Services—Services that do not need an overnight stay in a hospital. These services are often provided in a doctor’s office, hospital or clinic.

Out-Of-Pocket Maximum—The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copays and coinsurance, your health plan pays 100 percent of the costs of covered benefits. The out-of-pocket maximum doesn’t include your monthly premium payments or anything you spend for services your plan doesn’t cover.

PPO—Preferred Provider Organization. A type of managed care health insurance plan that provides benefits if you visit a provider within the network.

Urgent Care Provider—A provider of services for health problems that need medical help right away but are not emergency medical conditions.