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Home > Benefits > Medical Care Plans > Definitions


The member's share of the cost of a covered service. For example, if a plan pays 80%, the member's co-insurance is 20%.

Co-pay or Co-payment
A fixed amount paid for a covered service, for example, $75 for urgent care.

The dollar amount of covered services an individual must pay each plan year before the plan begins reimbursement.

In-Network Benefits
Benefits for covered services rendered by a network of contracted physicians and hospitals. Users of In-Network providers receive greater benefits for services.

Any person covered under a plan, including employee, spouse/domestic partner or child. Sometimes also referred to as enrollee or participant.

A group of physicians and hospitals who have contracted to provide medical services at a reduced rate.

Out-of-Network Benefits
Benefits for covered services rendered by non-contracted physicians and hospitals. PPO plans cover services both In- and Out-of-Network. Exclusive provider network plans do not cover Out-of-Network providers except for emergency care away from home.

Out-of-Pocket Maximum
The out-of-pocket maximum helps protect you from high medical bills. Once the health plan's out-of-pocket maximum is reached, the plan pays 100% of covered charges for the remainder of the plan year. Plan deductible and percent co-insurance count toward the out-of-pocket maximum. Fixed dollar co-payments (e.g., urgent care, emergency room ) are covered without a deductible; they count only toward the out-of-pocket maximum, not the deductible.

Preferred Provider Organization (PPO)
A Preferred Provider Organization is a medical plan that uses a network of contracted physicians and facilities to provide services at discounted rates. Network providers write-off amounts in excess a contracted rate (the allowed amount). A PPO gives members the option of using providers outside the network; however the member has a separate deductible and higher co-insurance and can be balance billed for charges in excess of the allowed amount.

Preventive Services
Evidence-based services as recommended by the US Preventive Services Task Force and the Center for Disease Control.

Primary Care Physician (PCP)
A network physician selected by the member to provide routine care and recommend specialty care. PCPs include general and family practice physicians, internists, and pediatricians who provide basic care.

Routine Eye Exam
An annual exam performed to detect undiagnosed eye health problems and to measure visual acuity (refraction). An annual eye exam for those with diabetes is covered as routine. Eye exams for individuals with diagnosed eye disease are not generally routine.

Specialty Drugs
High cost, scientifically engineered drugs that are usually injected or infused.

Page updated: 4 October 2013
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