Guides
The basics of health benefits
General information to help you understand the words and paperwork. Details vary from plan to plan, so always check your own plan documents.
Glossary
- Premium
- The amount you pay on a regular schedule to keep your coverage active, whether or not you use care.
- Deductible
- The amount you pay for covered care each year before your plan starts sharing the cost.
- Copayment (copay)
- A fixed amount you pay for a specific service, such as a doctor visit or a prescription.
- Coinsurance
- Your share of the cost of a covered service, shown as a percentage, after you have met your deductible.
- Out-of-pocket maximum
- The most you pay for covered care in a plan year. After you reach it, the plan pays covered costs.
- Network
- The doctors, hospitals and other providers that have agreed to work with your plan. Costs are usually lower inside it.
- Prior authorization
- Approval your plan may require before it will cover a particular service or medicine.
- Formulary
- The list of prescription drugs a plan covers, often grouped into tiers that cost different amounts.
- Explanation of benefits (EOB)
- A statement from your plan showing what was billed, what it paid and what you may owe. It is not a bill.
Simple checklists
Reading a benefits summary
- Find the premium, deductible and out-of-pocket maximum first.
- Check whether your doctors and hospitals are in the network.
- Look up your regular medicines in the formulary.
- Note which services need prior authorization.
Questions worth asking
- What will I pay before the plan starts to share costs?
- What is the most I could pay in a year?
- Is this provider or medicine covered, and at what cost?
- What happens if I need care away from home?
Keeping your records
- Save every explanation of benefits you receive.
- Compare each EOB with the bill before you pay.
- Keep notes of calls, including the date and the name of the person you spoke with.
- Ask for anything important in writing.