2024-Framebridge-Benefit Guide

MEDICAL TERMINOLOGY

CALENDAR YEAR MAXIMUM Total dollar amount a plan pays during a calendar year toward the covered expenses of each person enrolled. COINSURANCE A percentage of the medical costs, based on the allowed amount, you must pay for certain services after you meet your annual deductible. COPAYMENT/COPAY A set dollar amount you pay for network doctors’ office visits, emergency room services and prescription drugs. DEDUCTIBLE Total dollar amount, based on the allowed amount, you must pay out-of-pocket for covered medical expenses each calendar year before the plan pays for most services. The deductible does not apply to network preventive care and any services where you pay a copayment rather than coinsurance. Some of your dental options also have an annual deductible, generally for basic and major dental care services. DEPENDENT COVERAGE Insurance coverage for family members of the policyholder, such as spouses, children, or partners. IN-NETWORK A doctor or facility providing care and has negotiated a contract rate with your health insurance company. You may not be balanced billed for amounts over the negotiated contract rate. NETWORK A group of health care providers, including dentists, physicians, hospitals and other health care providers, that agrees to accept pre-determined rates when serving members. OUT-OF-NETWORK A doctor or facility providing care and does not have a contract with your health insurance company. You may be balance billed for amounts over the percentage of costs paid by the insurance company (coinsurance).

OUT-OF-POCKET MAXIMUM The maximum amount of coinsurance a Plan member must pay towards covered medical expenses in a calendar year for both network and non-network services. Once you meet this out-of-pocket maximum, the Plan pays the entire coinsurance amount for covered services for the remainder of the calendar year. Deductibles and copays apply to the annual out-of-pocket maximum. PRESCRIPTION DRUG COVERAGE Health insurance or plan that helps pay for prescription drugs and medications. PREVENTATIVE CARE (PREVENTATIVE SERVICES) Routine health care, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease or other health problems. PRIMARY CARE PHYSICIAN (PCP) The health care professional who monitors your health needs and coordinates your overall medical care, including referrals for tests or specialists. PROVIDER Any type of health care professional or facility that provides services under your plan. QUALIFYING EVENT An occurrence that qualifies the Subscriber to make an insurance coverage change outside of the Open Enrollment. SPECIALIST A physician 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. A non-physician specialist is a provider who has more training in a specific area of health care. USUAL AND CUSTOMARY ALLOWANCE Usual and customary allowance is the amount of money that a particular health insurance company determines is the normal or acceptable range of payment for a specific health-related service or medical procedure.

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