Terms that you should know
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Coinsurance
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The percentage of eligible expenses you and the plan share. The exact coinsurance depends on the plan your employer offers. |
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Co-Payment
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The fixed, up-front dollar amount you pay for covered expenses. Co-payment amounts do not apply toward your deductible or co-insurance, and they do not accumulate toward the out-of-pocket maximum. |
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Deductible
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Initial amount you must pay each benefit year for covered services before the plan begins to provide benefits. |
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In-Network Care
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Care you receive from in-network physicians, specialists, hospitals, rehabilitation centers, labs and other healthcare providers that have signed an agreement with their local Blue Cross and Blue Shield plan. In-network providers accept the allowable charge as payment in full. They also file claims for you. In-network care is paid at the higher level of benefits. |
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Out-of-Network Care
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Care you receive from healthcare providers who are not in the network. This care is covered at the lower, out-of-network level when it is determined to be medically necessary and appropriate. |
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Out-of-Pocket Maximum
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The amount you pay out of your pocket for eligible healthcare expenses before the plan begins to pay 100% for additional eligible expenses. The out-of-pocket limit does not include co-payments, deductibles, mental health/substance abuse expenses, prescription drug expenses, or amounts over the allowable plan charge. |
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(PPO) Preferred Provider Organization Program
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A program that does not require the selection of a primary care physician, but is based on a provider network made up of physicians, specialists, hospitals and other healthcare facilities. Using this provider network helps assure members receive coverage for eligible services. |