Billing & Insurance

Important Insurance Terms to Know

A network includes all of the various facilities and providers that are contracted with your health insurance company to provide healthcare services.  

• In-Network – A health care provider or facility that has a contract with an insurance company. When you receive care from an in-network provider, generally you pay less. These providers may also be called “preferred providers” or “participating providers”. Contact your insurance company to find out if a provider is “in-network” or not. Keep in mind that networks can change. It's a good idea to check with your provider or your insurance company each time you make an appointment.

• Out-Of-Network – health care provider or facility that does not have a contract with the insurance company. If you receive care or services from an out-of-network provider, typically you will end up paying more.

A deductible is the amount you pay out-of-pocket for covered healthcare services before your insurance plan will start to pay. Sometimes the deductible may not apply to certain services but will apply to others. You can call your insurance company to ask about the specifics of what does and doesn’t apply to the deductible.

• For example: If you have a $400 deductible, you will pay the first $400, and then your health insurance plan will begin to pay a portion of your healthcare costs. 

Co-insurance is the amount (usually a percentage) of each bill you must pay out-of-pocket, after you have met your deductible.

• For example: If your health insurance plan’s allowed amount for an office visit is $100, and you’ve met your deductible, and if you have a 20% co-insurance, then your portion of the bill for an office visit would be $20. Your health insurance plan would then pay the remaining $80. 

A co-pay is the fixed amount of each bill you must pay out-of-pocket. The co-pay is either due at the time of service, or gets billed to you after your visit.

• For example: If you have a $30 co-pay for a visit to a specialist, you would pay that $30 and your health insurance plan would pay any remaining balance for your visit.

The guarantor or policyholder is the person that the health insurance policy is under (i.e. the person who pays for the health insurance policy). In a family plan, this is typically a parent.

Health Insurance Coverage/ Covered Services or Health Insurance Benefits is the services and procedures that a health insurance plan will pay for.

Non-covered services or exclusions are conditions or services that the insurance company will not pay for.

A premium is the amount that the policyholder pays for your health insurance coverage each month.

An out-of-pocket maximum is the maximum amount of money you will pay out-of-pocket for covered healthcare expenses during a plan year.

• For example: If you have a $5,000 out-of-pocket maximum, after you’ve met your deductible, you would pay a co-pay or co-insurance towards your out-of-pocket maximum. Once you’ve reached that $5,000 maximum, your health insurance plan will pay 100% of all your medical expenses.

An Explanation of Benefits (EOB) is a statement you receive from your insurance company that shows the services and procedures performed, the amount your health insurance plan paid for those services/ procedures, and any remaining balance that you will be responsible for. An EOB is not a bill.