Page 4 - PA_HMO_Member_Kit

Basic HTML Version

3
Important Health Plan Words to Know
Deductible
A deductible is a fixed amount of money you pay before your plan’s benefits enter into effect. Let’s say
you have a $500 deductible based on the plan you chose. Once you’ve paid $500 out of pocket
(i.e., with your own money) for medical services, your health plan benefits will begin to cover costs
and you’ll only pay portions of your bills with copays and coinsurance. A general rule with deductibles
is: The higher the deductible, the lower the monthly premium – and the higher the monthly premium,
the lower the deductible.
Copay
A copay is a flat-rate payment made each time you receive certain health care services, such as visiting
your doctor, seeing a specialist or picking up a prescription at the pharmacy.
Coinsurance
Instead of a flat-rate copay, coinsurance is a percentage that you pay when you receive a service that is
covered. For example, if your plan states that it will pay 80 percent of allowable charges for covered
services (after your deductible and/or copays have been met), then the remaining 20 percent is the
coinsurance amount you will pay.
Out-of-Pocket Maximum
In some cases, a member is required to pay no more than a maximum dollar amount in coinsurance,
copays and deductibles during a particular period. This amount is known as an out-of-pocket
maximum, and once it is reached, HAP pays 100 percent of covered expenses.
Personal Care Physician (PCP)
A PCP is a HAP-affiliated doctor who is usually an internist, general or family practitioner, or pediatrician.
The relationship you have with your PCP is important because he or she is the person who knows
your complete medical history and will make sure you get the right care you need – including care
from a specialist.