Healthcare benefits 101

Understanding common healthcare terminology

Premiums - The amount you pay each paycheck or month to have health insurance coverage, even if you don't use healthcare services.
Deductibles - The amount you must pay for covered healthcare services before your health plan starts paying a share of the costs.
Copays - A fixed dollar amount you pay for certain healthcare services, such as a provider’s visit or prescription medication.
Coinsurance - Your share of the cost of a covered healthcare service, usually shown as a percentage. For example, if your coinsurance is 20%, you pay 20% of the cost and your health plan pays 80%.

Out-of-pocket maximums - The most you’ll pay for covered healthcare services during a plan year. Once you reach this limit, your health plan pays 100% of covered services for the rest of the year.
Network - A group of providers, hospitals, pharmacies and other healthcare providers that have agreed to provide services at negotiated rates for members of your health plan.

Understanding network terms

In-network

Providers and facilities that have contracted with your health plan to offer services at discounted rates.

Out-of-network

Providers and facilities that do not participate in your health plan's network. Receiving care from these providers may result in higher costs or reduced coverage.

How to find in-network care

Using in-network providers is one of the easiest ways to lower your healthcare costs. In-network providers, hospitals, pharmacies and other providers have agreed to negotiated rates with your health plan, which can help reduce the amount you pay out of pocket.

Search before you schedule

Before making an appointment, search for a provider in the provider directory and then confirm that your provider, specialist, hospital or facility participates in your network.

Provider search tips

Confirm the provider's name, location and group/TIN.
Verify the provider participates in your specific network.
Check network status before receiving care, as provider participation can change over time.

Understanding your healthcare costs

Healthcare expenses can sometimes seem confusing. Understanding a few key terms can help you know what your health plan pays and what you may owe.

Billed amount

The amount a provider charges for a healthcare service.

Allowed amount

The discounted amount your health plan has negotiated with an in-network provider. This amount is often lower than the provider's billed amount.

What your health plan pays

After any applicable deductible, copay or coinsurance is applied, your health plan pays its portion of the allowed amount.

What you pay

Depending on your plan, you may be responsible for:

Deductibles
Copays
Coinsurance
Services not covered by your plan

Example

In this example, the provider's original charge was $500, but because the provider was in-network, the negotiated rate reduced the cost to $350. The health plan and member then share the cost based on the plan's benefits.

Provider charges: $500

Allowed amount: $350

Health plan pays: $280

Amount you pay: $70 coinsurance

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