Medical Benefits Terms

Allowed amount: The amount the plan has negotiated with network providers to accept as full payment. For example, if a service is covered at 90%, you pay only 10% of the allowed benefit, up to your out-of-pocket maximum. Out-of-network providers are not obligated to accept the allowed benefit as payment in full and may charge you more. This is called balance billing.

Balance billing: When an out-of-network provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $200 and the allowed amount is $155, $45 won’t be considered when your claim is processed and the provider may bill you for it. An in-network provider or facility cannot balance bill you for covered services. This does not get applied to your deductible or out of pocket maximum.

Coinsurance: The percentage of the cost you pay for certain covered services. The coinsurance percentage is lower for services received from in-network providers than for the same services from out-of-network providers.

Copayment: This is a fixed dollar amount you pay at the time service is rendered. This money goes directly to the health care provider and is applied toward your deductible.

Deductible: The amount you pay each year before your medical plan begins providing benefits for care.

EHP Network providers: These professional providers and facilities have contracts with EHP and have agreed to accept certain fees for their services. They submit insurance claims to EHP on your behalf. You are responsible for any copays, deductibles and coinsurance.

Out-of-pocket maximum: This is the most you will pay each year in deductible, copay and coinsurance charges. When the total amount you have paid in a year reaches the out-of-pocket limit, the plan will pay 100% of your copays and coinsurance for the remainder of the plan year (through Dec. 31).

Out-of-Network providers: These are professional providers and facilities who do not have a contract with EHP. Their services are subject to applicable copays, deductibles and coinsurance. These providers may balance bill you for charges above the allowed benefit amount.

Preauthorization: This is a decision by your insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. This is sometimes called prior authorization, prior approval or precertification. EHP may require preauthorization for some services before you receive them, except in an emergency.