Coinsurance is a percentage of the cost for a covered service that you are responsible for paying after you've met your deductible. For example, if your coinsurance is 20%, you pay 20% of the cost of the service.
A copay, or copayment, is a fixed amount you pay for a medical service or supply. Unlike coinsurance, it's a set dollar amount (e.g., $10) rather than a percentage, and you typically pay it at the time of service.
A deductible is the amount of money you must pay out-of-pocket for healthcare services before your insurance plan pays.
A formulary, also known as a drug list, is a list of prescription drugs that are covered by your insurance or prescription drug plan.
In-network refers to doctors, hospitals, and other healthcare providers that have a contract with your insurance company. Using these providers typically results in lower costs for you.
The Maximum Out-of-Pocket (MOOP) is the annual limit on what you'll have to pay for covered services. Once you reach this limit, you will not owe cost-sharing for Part A or Part B covered services for the remainder of the year. Some plans may also apply the MOOP to supplemental benefits such as vision, hearing, or dental.
A medical deductible is the amount you pay for your medical care before your insurance plan starts to help cover the costs. Not all plans have this deductible.
Out-of-network refers to doctors and hospitals that do not have a contract with your insurance company. If you see an out-of-network provider, you may pay more out-of-pocket.
Out-of-pocket costs are the expenses you must pay for a portion of the services or drugs you receive. This includes things like deductibles, copays, and coinsurance.
A Part D deductible is the amount you must pay for prescription drugs before your Medicare Part D plan starts to help with the costs. Not all plans have this deductible.
A premium is the periodic payment you make to Medicare, an insurance company, or a healthcare plan to maintain your health or prescription drug coverage.
A referral is a written order from your primary care doctor that allows you to see a specialist or get specific medical services. Many plans, like HMOs, require a referral for you to see any provider other than your primary care doctor. You do not need a referral with Clover Health HMO and PPO plans.
Tiers are groups of drugs within a formulary that have different costs. Generally, drugs in a lower tier are less expensive for you than drugs in a higher tier.