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Understanding your explanation of benefits (EOB)

Glossary of Terms

  • Explanation of benefits (EOB)- The statement sent to Participants (members) by their health plan (insurance company or third party plan administrator) that lists services provided, amount billed, payment made for a specific treatment and the claims appeal process.

  • Copayment- the charge you are required to pay for certain Covered Health Services.  A copayment may be either a set dollar amount or a percentage of eligible expenses.

  • Deductible (shown as 'Deduct" on the EOB)- The fixed dollar amount that you must pay each year toward covered medical expenses before your plan benefits are payable. 

  •  Coinsurance-  is a percentage of a medical charge that you pay, with the rest paid by your health insurance plan, that typically applies after your deductible has been met. For example, if you have a 20% coinsurance, you pay 20% of each medical bill, and your health insurance will cover 80%.

  • Out-of-pocket maximum: The most you could have to pay in one year, out of pocket, for your health care before your insurance covers 100% of the bill. Here you can see the maximums allowed by the government for private plans for this year.

  • Network: The group of doctors and providers who agree to accept your health insurance. Health insurers negotiate lower rates for care with the doctors, hospitals and clinics that are in their networks.

  • Out-of-network: A provider your insurance plan has not negotiated a discounted rate with. If you get care from an out-of-network provider, you may have to pay the entire bill yourself, or just a portion, as indicated in your insurance policy summary.

  • In-network: A provider who has agreed to work with your insurance plan. When you go in-network, your bills will typically be cheaper, and the costs will count toward your deductible and out-of-pocket maximum.

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