Once you have signed up for medical coverage, you will receive plan details that show everything you are covered for and how much you are covered. The most detailed version of this is called the Summary of Benefits & Coverage (SBC).
There are common terms and phrases that are universal across all medical plans and carriers. Let’s break down some of the most common components of medical plans.
In-Network - refers to providers and facilities that are part of a health plan’s network of providers and has negotiated favorable rates for treatment. You can find whether your provider is in-network through your carrier’s website.
Out-of-Network - refers to providers and facilities that do not have a preferential relationship with your health plan. Typically, coverage is less and costs are higher, but lots of plans still provide some type of coverage (except EPOs and HMOs).
Deductible - the amount you pay before health care coverage kicks in. Ex. $500 deductible means you pay $500 before your insurance starts covering things.
OOP Max - Out of Pocket Max is the most you will have to pay for covered services. This is like a cap on your expenses. After this amount, insurance covers everything.
Co-pay - a flat dollar amount that is the cost to receive certain services like a doctor’s visit or urgent care.
Co-insurance - this is how much you pay vs what insurance pays once you have hit your deductible. If you see 80% co-insurance on a plan, that means your plan covers 80% of costs and you pay 20%.
Primary Care Physician (PCP) - your “doctor”; your first line of contact for general health questions and check ups. They can also refer you to specialists for more specific needs.
Specialist - specialists have expertise in a particular area and can handle more detailed questions and concerns that your primary care physician may not have expertise in.
Emergency Room - treats urgent medical conditions. Be aware that if you do go to an emergency that isn’t In-Network, they will still give you care!
Urgent Care - treats conditions, illness or injury that is not life-threatening, but still needs medical care.
Knowing these terms will put you in a great place to evaluate which plans are best for your medical needs. If you have questions or want to know what the best plan is for you, reach out to Rollfi!
