Medical

Medical Definitions

Deductible: The amount you pay each calendar year before the plan starts paying for covered services. A family deductible is the total amount you and your covered dependents need to pay each plan year before the plan starts paying for covered services.

Your Deductible will include payments for services such as Diagnostic Testing (x-ray, blood work) if service is NOT performed as a part of an office visit, Diagnostic Imaging (CT/PET scans, MRI) if service is NOT performed as a part of an office visit, outpatient surgery, etc.

Co-Pay: The amount you pay toward a doctor’s, urgent care or emergency room visit when enrolled in the medical plan. This is also the amount you will pay at the pharmacy for prescription drugs under the medical plan.

Coinsurance: The percentage you must pay of the allowed amount for covered health services after the annual deductible has been met, but before the out-of- pocket maximum has been reached.

Out-of-Pocket Maximum: The most you will pay for covered services during the calendar year before the health plan begins to pay at 100% of covered charges. Your Out-of-Pocket Maximum will include your deductible, copays and coinsurance payments. This limit does not include per pay contributions for healthcare nor does it cover services not covered under the health plan.

Non-Emergency Use of the Emergency Room: Coverage is not provided for services and supplies for the institutional charges and Physician related to non-emergency use of an emergency room. An emergency is a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

• Placing an individual’s health in serious jeopardy, or with respect to a pregnant woman, the health of the woman or unborn child;
• Result in serious impairment to the individual’s bodily functions; or
• Result in serious dysfunction of a bodily organ or part of the individual.