A provider network is a list of the doctors, other health care providers, and hospitals that belong to a Preferred Provider Organization (PPO). Health plans often include access to a PPO network so that plan members have access to contracted providers. These providers are called “network providers” or “in-network providers.” A provider that hasn’t contracted with the PPO is called an “out-of-network provider.” Check your plan document or member ID card to see if your plan includes access to a provider network.
faqs
A little knowledge goes a long way when it comes to understanding your benefits!
At Coeur, we’re dedicated to member service. To help you navigate and better understand your healthcare plan, we’ve put together a list of terms to know and answered a few common questions.
FAQs
A deductible is the set out of pocket amount that a plan member is responsible for paying per year before the health plan will cover the cost of medical treatment. Check your plan document to see what your set deductible cost is, what services it applies to, and how much you pay for covered services after you meet the deductible.
A health plan copayment is a fixed amount a plan member is responsible for paying for sharing the cost of certain health services between the health plan and the plan member. Health plans are a partnership between plan members and the employer sponsoring the plan. The cost-sharing system is an important aspect of the plan. Pay special attention to the cost-sharing structure of the health plan you are considering or enrolled in. Whether the plan is just for your or your covered dependents, anyone enrolled in the plan may be required to pay cost-sharing when they receive medical care. A copay or copayment is a fixed fee for certain kinds of office visit, prescription drugs, or other kinds of care. The health plan document tells you exactly which services will incur this fee and how much you will owe.
Coinsurance is a form of cost sharing between the plan participant and the health plan. The participant pays a share of the payment made against the claim, usually represented in a percentage. For example, if the plan is 80/20, your health plan would cover 80% of the claim, and you would pay 20%. Check your plan document to see what services coinsurance applies to.
An out of pocket maximum is the most you will pay for covered services within a plan year. After you meet your out of pocket maximum, your plan pays 100% of the cost of covered benefits. Check your plan document to see what expenses apply towards your out-of-pocket maximum.
A dependent is a spouse or child that is covered by the primary member’s health plan. Check your health plan document to see who qualifies as a dependent under your plan.
The effective date is the date that your coverage begins.
A healthcare provider, hospital or pharmacy is considered in-network if they are part of the health plan’s preferred providers organization (PPO) network. These providers have agreed to provide services to plan members for a discounted rate. An out-of-network provider is one NOT contracted with the PPO. If you visit a physician or other provider within the PPO network, the amount you will be responsible for paying will be less than if you go to an out-of-network provider. Though there are some exceptions, in many cases, the health plan will pay less for services you receive from out-of-network providers and you’ll be responsible for paying the difference between the provider’s full charge and your plan’s payment amount. That is called balance billing.
Preventive care services are intended to help you stay as healthy as possible. Services include routine wellness visits, immunizations, certain tests and screenings. Your primary care provider can help you coordinate what tests and shots are right for you. They may consider things like family history, age, sex, current health status, and more. Refer to your Employer Health Plan Document to determine your specific coverage.
To see a complete list of preventive care services: https://www.healthcare.gov/coverage/preventive-care-benefits/
To see a list of preventive vaccinations: https://www.cdc.gov/vaccines/
Understanding an EOB
After a plan member has visited a doctor, clinic, or hospital for care, the provider will file a claim with the health plan. An explanation of benefits (EOB) is a statement sent by the health plan administrator each time a claim is processed. The EOB tells the plan member and the provider what portion of the charges are eligible for benefits under the health plan. It lets the member and provider know how the health plan covered the cost of a service and what amount is still owed, if any. The EOB is not a bill, but it explains what was covered and the provider may bill the member separately for responsible charges.
An EOB is not a bill, but will show if you are is responsible for any remaining payment to the medical service provider. The provider will bill you for any remaining payment.
Understanding Billing
Balance Billing refers to any amount left after the amount your health plan has covered.
When you visit a provider who is a part of your PPO network, you receive a network discount and are not responsible for any balance bills received.
If you visit a provider who is not a part of your PPO network, your health plan will cover up to a certain dollar amount. Any amount left unpaid is then the responsibility of the member.