Knowledge Check

3. Out-of-pocket ___________ The most a member will have to pay for covered services in a plan year. After they have spent this amount on deductibles, copayments, and coinsurance, their health plan will pay 100% of the cost for any additional of covered benefits.
6. Maximum amount on which payment is based for covered health care services is called the _______ amount
7. A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.
8. A fixed dollar amount a member will pay at the time services are rendered. Typically copays apply to office visits, prescriptions or hospitalizations.
9. The portion of health care charges that a member will pay before their insurance starts covering it.
10. A specified percentage of the cost of treatment the insured is required to pay for all covered medical expenses remaining after the deductible has been met

1. If you reach your out-of-pocket maximum, your insurer (EMI) will cover 100% if you are in-________
2. _______ billing is an unexpected bill that can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
4. ________ billing is when out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service.
5. These are either in-network or out of network (also know as Preferred or Non-Preferred)