Plan designs for 2012 use terms that may be new to members.
Claim – Provider charges to be reimbursed for services you received
Coinsurance – Percentage of a provider’s charge for which you are responsible
Copay (Copayment) – Flat-dollar amount you must pay when visiting a provider
Cost-share – Provider charges you pay; includes deductibles, coinsurance and copays
Coverage Tier – Choice of coverage for dependents, including spouse or domestic partner
Covered Services – Services for which a plan may make a payment to a provider
Decline – Choice not to participate in PEBB, with no benefits or employer contribution
Deductible – Amount you pay for covered services before the plan begins paying claims; not all covered services are subject to the deductible.
In-Network Provider – Provider who contracts to be part of the plan’s network and agrees to the plan’s rules and fee schedules
Opt out – Choice of coverage through anoth er employer-sponsored group health plan; may afford cash in your pay as determined annually by the Board (click here for info)
Out-of-network Provider – Provider who doesn’t contract to be part of a plan’s network and for whose services you pay a higher portion of costs
Out-of-pocket Maximum –Annual limit on all member cost-sharing; doesn’t include premiums, balance-billed charges or charges for services not covered
Premium – Periodic payment required to keep a fully insured policy in force
Premium Equivalent – Periodic payment required to sustain claims payment and reserve funds in a self-insured plan
Preventive Benefits – Covered services intended to prevent disease or identify disease while it is more easily treatable; not subject to deductibles, co-payments or coinsurance
Provider – Licensed health care professional, hospital or facility.