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 Medical Question and Answer

What is a co-payment?

A co-payment is the flat dollar amount that a subscriber has to pay for services covered under his/her health plan, such as visits to a physician.

What is a deductible?

A deductible is the amount the subscriber must pay for covered services before the insurance company assumes responsibility for all or part of the remaining costs for covered services.

What is coinsurance?

Coinsurance is the portion of the cost for covered services that is the responsibility of the subscriber (e.g. 80%/20% means the insurance company pays 80% of the cost and the subscriber is responsible for the remaining 20%).

What is an out-of-pocket maximum?

Out-of-pocket maximum is the most you will ever pay for covered medical services during a plan year.

What is preventative medicine?

Preventative medicine is a set of measures taken in advance of systems to try and prevent illness or injury. Examples of preventative care are routine physicals, immunizations, and well-childcare. 

What is a referral and when do I need one?

A referral is approval that allows you to receive medical care from a health care provider other than your primary care doctor. Please reference your plan booklet to see if your insurance plan requires referrals. 

What is pre-authorization and when do I need to get it?

Pre-authorization is the process of obtaining approval prior to a service or medication. Without pre-authorization, the service or medication may not be covered. In addition to certain medical services, certain medications are subject to pre-authorization to be eligible for coverage under your pharmacy benefit.

How do I find out if my doctor is an in-network provider?

To find out if a doctor is a participating in-network provider, visit the insurance carrier's website and search the provider listings. Each insurance carrier does publish a listing of providers in network for each plan once a year. However, the online listing is generally updated more frequently.

If my doctor orders blood work, do I need to make sure the lab is in network?

Yes. If you are receiving any service outside of your primary physicians office, make sure they are in-network. Check with your insurance carrier or check with the office where you are getting the procedure done.
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