Copay – Coinsurance – OOP max – OV; the jargon is mind boggling. Let me explain. Or call us (760) 745-5151.
Copay; A fixed dollar amount paid directly to a provider at each visit. It may not count toward annual deductible. Could be $15 $20 $30 or more.
Coinsurance; A percentage of cost paid by you, usually after meeting a deductible. Example: you pay 20% carrier pays 80% of bills. Your costs are limited to the OOP max.
Deductible; Amount you pay before the benefits begin. Costs accumulate towards an annual deductible.
OOP Max; Out of pocket maximum. Maxiumum amount you will pay in a calendar year, usually a combination of deductible and coinsurance.
Individual; if enrolled as a single person, these deductible and OOP max limits apply to you.
Family; If enrolled as a family, these deductible and OOP max limits apply to each person – usually double individual. Some exceptions.
Provider; Any doctor, medical group, hospital, lab, etc. providing medical services.
Rx formulary; List of covered drugs by a particular plan. Can be generic or brand name.
Non formulary; Drugs not on the Rx formulary list. May or may not be covered by the plan.
COBRA; Consolidated Omnibus Budget Reconciliation Act. Option to continue group coverage after termination. Lasts 18 – 36 months. Cost is 2- 10% higher.
Carrier; Same as insurance company. They “carry” your plan.
Network; allowed list of doctors, hospitals and other service providers. Services have been pre-negotiated between provider and carrier.
OON; “Out of network” providers who are not on the list, therefore not preferred and have not negotiated. If covered by your plan, you will pay more, plus you could owe the provider the difference.
Guaranteed issue; Carrier can’t deny enrollment to any eligible employee regardless of health condition. California law for small group plans (2- 50). At this time it does not apply to individual plans but that could change soon. Pre-existing conditions may have a waiting period.