The following are definitions of terms used in the description of medical coverage. Understanding these terms will make it easier to compare the benefits provided under each of the plans.
The portion of a charge that the plan determines is reasonable for covered services that have been provided to the patient. Also known as the “allowance.” Amounts in excess of the allowed charge are not paid by the plan. If the services were provided by aparticipating provider, the amount in excess of the allowed charge is waived by the provider. If the services were provided by a non-participating provider, the patient may be responsible for paying the additional amount (see Balance Billing).
The amount you pay each year out of your own pocket before your medical plan covers a portion of the cost for covered expenses through coinsurance. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. Note that if you enroll in any coverage level other than “employee only” for the High Deductible Health Plan (HDHP), you will need to meet the entire family deductible before the plan pays benefits. Any one family member, or any combination of family members, can satisfy the deductible.
When a provider bills you for the difference between the provider’s charge and the allowed amount under your benefit plan. For example, if the provider’s charge is $100 and the allowed amount under your plan is $70, the provider may bill you for the remaining $30. An in-network provider (sometimes called a preferred provider, depending on your plan) may not balance bill you for covered services.
The way you share in the cost for most covered services after you meet the deductible. For example, if the coinsurance amount is 80%, then your medical plan pays 80% of the cost and you pay for the remaining 20% out-of-pocket. When you choose an in-network provider, the coinsurance you pay is significantly lower than for an out-of-network provider.
A fixed amount (for example, $25) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service (e.g., office visit for a pediatrician vs. specialist visit for an orthopedist).
The charge for services rendered or supplies furnished by a provider that qualifies as an eligible service and is paid for in whole or in part by your plan. May be subject to deductibles, copayments, coinsurance, or maximum allowable charge, as specified by the terms of the insurance contract.
A service or supply (specified in the plan) for which benefits may be available. The plan will not pay for services that are not covered by the plan.
Individuals who rely on you for support including children and spouse, generally qualify as dependents for health care and insurance benefits.
Emergency Room Care
Care received in an emergency room.
Formulary (Prescription Drug Coverage)
The Plan includes a list of preferred drugs that are either more effective at treating a particular condition than other drugs in the same class of drugs, or as effective as and less costly than similar medications. Non-preferred (non-formulary) drugs may also be covered under the prescription drug program, but at a higher cost-sharing tier. Collectively, these lists of drugs make up the Plan’s Formulary. The Plan’s Formulary is updated periodically and subject to change. To check where your medications fall within the plan’s formulary please call Express Scripts at 1-866-383-7420.
Doctors and other health care providers, hospitals, clinics, laboratories and outpatient facilities that have negotiated discounted rates with your plan. Depending on your plan, you may have the choice to receive care from either an in-network provider or an out-of- network provider, but you’ll generally pay more if you choose to see an out-of-network provider. In some cases, your plan will refer to network providers as “preferred” providers.
Maximum Allowable Charge (MAC)
The limit the plan has determined to be the maximum amount payable for a covered service.
Doctors and other health care providers, hospitals, clinics, laboratories and outpatient facilities that do not have negotiated discounted rates with your plan. You will generally pay more when you receive care from an out-of-network provider because that provider is not bound by contracted pricing. You are responsible for paying the difference between the amount the plan is willing to pay (sometimes called the maximum allowable charge) and the provider’s charge.
The most you will pay during the plan year for in-network care before your plan begins to pay 100% of eligible expenses. This limit does not include your premium or expenses for services not covered by your plan, nor does it include balance billing, amounts above the Maximum Allowable Charge (MAC) for your plan, or out-of-pocket costs for Davis Vision plan services and products. It’s important to check your plan and see what other charges may not be included.
A provider who has a contract with your plan to provide services to you at a discount. In some cases, there may be a “preferred network” as a subset of your plan’s overall network. In this instance, preferred providers offer additional savings on covered services.
Primary Care Physician (PCP)
A physician who directly provides or coordinates a range of health care services for a patient. You are required to select a primary care physician (PCP) to receive benefits through the HMO plan.
A health insurance premium is the monthly fee that is paid to an insurance company or health plan to provide health coverage. You and Lehigh both contribute to pay the cost of your premium, with Lehigh paying the majority of the cost.
Medications that by law require a prescription.
Any covered service or supply that is received in the absence of symptoms or a diagnosed condition. Preventive care includes preventive health services like physical examinations, certain immunizations screening tests, and dental cleanings. Preventive care can also provide specific programs of education, exercise, or behavior modification that seek to manage disease or change lifestyle: programs for diabetes management, smoking cessation, childbirth preparation etc. Medical plans clearly define the types of services, supplies, and programs they offer as preventive benefits and they provide them based upon protocols established in the medical community with regard to factors like frequency, patient age, and suitability. The Patient Protection and Affordable Care Act also requires particular preventive services for particular individuals to be covered at no cost, provided the covered services are received from a network provider. These services can be reviewed at www.healthcare.gov/preventive-care-benefits.
A specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. The Keystone HMO plan requires a referral to see a specialist, while the PPO plans and the HDHP do not require a referral.
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Any covered medical service or supply that is received in the absence of symptoms or a diagnosed medical condition. Wellness care includes preventive health services like physical examinations, certain immunizations, and screening tests. Wellness care can also provide specific programs of education, exercise, or behavior modification that seek to manage disease or change lifestyle — programs for diabetes management, smoking cessation, childbirth preparation — and the like. Medical plans clearly define the types of services, supplies, and programs they offer as wellness benefits, and they provide them based upon protocols established in the medical community with regard to factors like frequency, patient age, and suitability.