Key Terms

• Coinsurance: is the percentage of costs that you pay for a service after you meet your benefit period deductible.
• Copay: is a fixed dollar amount that you must pay for a medical service.
• Deductible: the amount you are responsible for paying before your insurance plan begins to pay for covered services.
• Health Care Flexible Spending Account: can be used for eligible medical, dental, and vision expenses.
• Health Savings Account (HSA): a type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses if you are enrolled in the High Deductible Health Plan (Duke Advantage).
• High Deductible Health Plan (HDHP): plan with a higher deductible than a traditional insurance plan. The monthly premium is usually lower. A high deductible health plan can be combined with a health savings account (HSA) for you to pay for certain medical expenses.
• HMO: a health plan option which typically limits member coverage to medical care provided by doctors, hospitals, and other healthcare providers within its network, except for emergencies and out-of-area urgent care.
• In-Network Provider: any healthcare provider (physician, hospital, urgent care or other facility) that is contracted by the insurance administrator to provide health care services.
• Limited Purpose Flexible Spending Account (LPFSA): a special type of flexible spending account designed for individuals who are enrolled in a high deductible health plan and want to remain eligible to contribute to a Health Savings Account (HSA).  An LPFSA can typically only be used for certain expenses, such as dental and vision.
• Out-of-Network Provider: any healthcare provider that does not belong to your insurance company’s preferred provider network. If the Out-of-Network provider charges more for a service than your insurance company agrees to pay, you will need to pay the difference (often referred to as balance billing). This payment does not count toward your out-of-pocket limit.
• Out-of-Pocket Limit: the maximum dollar amount that a member or family could pay in a year for covered services before the plan pays 100%. Any deductible, copay, and coinsurance amounts that you pay count towards the out-of-pocket limit.
• PPO: a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.
• Prior Authorization: a requirement that services must be evaluated to assess the medical necessity and cost of care before the service is authorized.