Balance billing: When a provider bills a patient for the difference between the amount they charge and the amount the patient’s insurance has approved. This generally occurs when you receive care from out-of-network providers.
Coinsurance: The percentage of the cost you pay for a health care service. If your coinsurance is 20%, you pay 20% of the cost, and the plan pays 80%.
Copay: A fixed dollar amount for certain visits, prescription drugs, and procedures.
Coordination of benefits: When you’re enrolled in more than one plan, one plan becomes the primary plan and pays for medical expenses first.
Covered: Being covered for something means that it’s part of your health insurance benefits package. You may still need to pay a copayment, coinsurance, or a deductible, even if something is covered.
Covered-in-full: If something is covered-in-full, it means that the benefit is paid entirely by your insurance plan. In other words, it’s free to you.
Claims: Requests for your plan to pay for services you receive.
Deductible: The amount you pay for covered services before the plan begins paying a portion of the cost. Each year, you pay 100% of your covered expenses before the deductible is met.
Explanation of Benefits: This statement shows the breakdown of how your insurance plan processes your claims. This is not a bill.
Network or in-network providers: Doctors, facilities, and other providers who have agreed to a discounted rate negotiated by Aetna. You may also see this referred to as “Preferred Care”. You save money when you use providers in Aetna’s Preferred Provider Network.
Out-of-pocket maximum: The most you will pay for covered medical expenses—copays, coinsurance, and deductibles—before your plan begins to pay 100% of covered medical expenses.
Out-of-network providers: Doctors, facilities, and other providers who are not part of the Aetna network. Generally, you’ll pay more for care when you use an out-of-network provider. You may also see this referred to as “Non-Preferred Care”.
Non-Preferred Care: Doctors, facilities, and other providers who are not part of the Aetna network. Generally, you’ll pay more for care when you use an out-of-network provider. You may also see this referred to as “out-of-network providers”.
Preferred Care: Doctors, facilities, and other providers who have agreed to a discounted rate negotiated by Aetna. You may also see this referred to as “Network or in-network providers”. You save money when you use providers in Aetna’s Preferred Provider Network.
Premium: The amount automatically billed to your student account that pays for your insurance coverage during the policy period.
Qualifying life event: A change in your situation that can make you eligible for a special enrollment period, allowing you to enroll in health insurance outside of the yearly Open Enrollment Period.
Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. You need to get a referral before you can get medical care from anyone except your primary care doctor. SHS can offer retroactive referrals if needed.
Subscriber/Policyholder: The individual who signs and is responsible for a contract with a health insurance plan. The subscriber is different from the enrollee, who is defined as anyone covered under the contract.
