Taking the mystery out of health plan language
The language of health coverage can be confusing. We’re here to make it simple for you. The more you understand your plan, the more you can take charge of your health and costs.
Below you’ll find definitions for some commonly used health coverage terms. Depending on your particular health plan, some of these terms may not apply to you — for instance, your plan may not have a deductible.
Understanding health care costs
The amount you pay for your health plan coverage, usually each month.
Any amounts you pay for covered services, not including your monthly premiums. These include:
A percentage of the charges that you pay for covered services. For example, a 20% coinsurance for a $200 procedure means you pay just $40.
The set amount you pay for covered services — for example, a $10 copay for an office visit.
The amount you pay for covered services each year before Kaiser Permanente starts paying. Depending on your plan, you may pay copays or coinsurance for some services without having to reach your deductible.
The most you’ll pay for covered services each year. For a small number of services, you may need to keep paying copays or coinsurance after reaching your out-of-pocket maximum.
Understanding bills and financial statements
The person who’s responsible for the costs of care under your health plan. If you’re the account holder of your health plan, most bills you get for your family’s care will be in your name.
You’ll get a bill in the mail or online whenever you have a balance after getting care, for instance, if your payment at check-in doesn’t cover the full amount you owe for services you get during your visit.
Explanation of Benefits
A summary of services you’ve received. It shows the charges, the date of your visit, and the name of the provider you visited. An Explanation of Benefits is not a bill.
The person whose name is on the health plan.
The subscriber may not be the same as the account holder — for example, if your parents have a plan but they designate you to pay their costs, you are the account holder and they are the subscribers.