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GLOSSARY OF TERMS

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Look below for a definition.

B

Benefits

The health care items or services covered under a health insurance plan.

C

Claim

A request for payment to you or your doctor for covered services or items provided to you.

Coinsurance

Your share of the costs of a covered service, shown as a percentage. For example, if a service costs $100 and your coinsurance is 20%, you would pay $20. MetroPlusHealth pays the rest of the cost.

Copay

The amount you pay for a covered service. The amount can vary based on the type of service.

Cost Sharing/Out-of-pocket costs

Your share of costs for covered services. Includes deductibles, copays and coinsurance.

Covered Services

The general term used to mean II of the health care services and supplies that are covered by our plan.

D

Deductible

An amount you could owe during your plan year for covered services before MetroPlusHealth begins to pay. For example, if your deductible is $500, you would pay the first $500 of covered heath care costs. Not everything you pay, such as your premium or costs of non-covered services, counts towards your deductible. For some covered services, MetroPlusHealth does not require your deductible to first be met before it will cover the costs.

E

Explanation of Benefits (EOB)

An EOB will be mailed to you after you receive health care (such as a visit to the doctor). The EOB includes what services your received, the costs, and what MetroPlusHealth paid. An EOB is not a bill.

F

Formulary

A formulary is the list of prescription drugs covered by your prescription drug plan or insurance plan that offers prescription drug benefits.

I

In-Network Providers

All doctors, hospitals, and other health care providers that work with MetroPlusHealth. You must use the network for all non-emergency care.

Inpatient Care

Health care that you get when you are admitted as an inpatient to a health care facility, like a hospital or skilled nursing facility.

O

Out-Of-Network Providers

Health care providers that do not have a contract with, or work with MetroPlusHealth.

Outpatient

Medical or surgical care that does not include an overnight hospital stay.

P

Premium

The amount that must be paid for certain types of insurance to keep your health insurance active.

Primary Care Provider (PCP)

A doctor or provider who gives, directs or helps you get health care.

R

Referral

A written order from your primary care doctor for you to see a specialist or get certain medical services.

last updated: December 7, 2023